After being dropped by their Medicare Advantage Plan, millions of seniors were left scrambling for health insurance

Some rural residents can no longer enroll in Medicare
Advantage Plans.

Privatized Medicare coverage, also known as Medicare Advantage Plans, stopped providing health insurance to residents in counties where profits were too slim or nonexistent. The shift in coverage options has disproportionately affected rural residents, reports Christopher Rowland of The Washington Post.

Over the past 20 years, Medicare Advantage Plans have grown exponentially by offering extra perks and low premiums to seniors seeking health care coverage that provides more benefits than traditional Medicare, but that trend has reversed. Rowland explains, "Insurers sharply retreated from the plans in some regions, saying rising health care costs and reduced government reimbursements have hurt profitability. . . . Hardest hit were a half-dozen rural states from New England to Idaho."

The sudden change "highlights one of the risks for Medicare Advantage beneficiaries, especially in rural areas where options tend to be meager: plans are under no obligation to offer coverage year-to-year," Rowland reports. "When profit margins are threatened, insurance companies can suddenly withdraw coverage."

Many rural counties have been the first to be cut off, leaving residents with traditional Medicare Part B, which has an 80/20 split, as their only option. Many seniors fear their 20% share will leave them with large medical bills.

In 2026, nearly 3 million people, or 10% of Medicare Advantage Plan beneficiaries, were dropped and forced to find other health care coverage, Rowland reports. "That’s a big jump from 2018 to 2024, when the rate of involuntary terminations was below 2% each year."

Lawmakers and health groups pushback on Rural Health Transformation Program plans and limits

Nebraska State Capitol in Lincoln
(Photo by Pieter van de Sande, Unsplash)

The excitement and energy that was first attached to millions of federal dollars in awards to states for the Rural Health Transformation Program has already started to fade. Some legislatures and health groups are resisting their state's proposals and pushing for more input on how the money is spent, report Arielle Zionts and Sarah Jane Tribble of KFF Health News.

The awards, which are funded through the Centers for Medicare & Medicaid Services, impose strict timelines and rules on the use and implementation of millions of dollars. Lawmakers, who must work quickly to pass bills needed to use the funds, and rural health groups are finding themselves at odds with award restrictions.

Much of the disconnect stems from what many lawmakers thought they could use RHTP money for, based on how the program was marketed, versus what CMS will allow.

The White House promoted RHTP awards as a way to "shore up rural health care," but their use isn't aimed at saving struggling rural hospitals. Instead, the funds are to be used for "seeding innovative projects and technologies," Zionts and Tribble explain. "States can use only up to 15% of their funding to pay providers for patient care."

Some state Republican lawmakers — especially those representing more rural regions — as well as rural hospital advocates, "are upset that the political rhetoric doesn’t match what they see," KFF reports. "They’re also lobbing criticisms at specific aspects of their states’ plans, including the proposed projects, what’s not included, and the spending approval process."

State lawmakers from Wyoming, Ohio, North Dakota, Michigan, North Carolina, Nebraska and Colorado all face conflicts and competing needs to get the work done so their states can spend the money and then decide who gets it, KFF reports.

Jed Hansen, executive director of the Nebraska Rural Health Association, told KFF, "Rural Health Transformation will not save a single hospital in our state. I don’t think it will save a hospital nationally.”

Wyoming officials aim to keep the state's Rural Health Transformation Program award going in 'perpetuity'

Wyoming is the most sparsely populated state in
the U.S. (Photo by Karsten Koehn, Unsplash)

As Wyoming's rural hospitals struggle to make ends meet and hire enough medical providers, state officials have hatched a plan using money from its Rural Health Transformation Program funds to buffer losses, create more robust provider training and incentives, while using investments to help the money stretch for decades, reports Arial Zionts of KFF Health News.

If Wyoming's plan receives federal approval to invest a substantial portion of its $205 million award, the state's "Rural Health Transformation Perpetuity fund could provide $28.5 million for the state to spend every year," Zionts explains. "Wyoming would spend the money on scholarships for health students and incentive payments to help keep small hospitals and rural ambulance services afloat."

The federal RHTP program requires states to spend their awards by established deadlines, or the money will be shelled out to other states. The question is, will the Centers for Medicare & Medicaid Services, which manages RHTP, see placing the money in an investment account as "spending it."

Stefan Johansson, the director of Wyoming’s health department, thinks it will. "He said that CMS called in December to specifically ask questions about the fund and that he believes the agency has formally approved it," Zionts reports. "But 'the devil’s always in the details,' he said, as the state works with CMS during the budget review period."

CMA has already told some states that RHTP grants "cannot be used to 'generate income.'" Zionts adds. "Wyoming officials wrote in the state’s application that the perpetuity fund won’t be making or keeping any profit. . . .Other states proposed funds in their applications, but Wyoming’s appears unique, according to a KFF Health News review of state applications."

States receive notice of how much money they will receive from the $10 billion Rural Health Transformation Program

Texas was awarded $281 million and New Jersey 
$147 million by CMS. (Adobe Stock photo) 

The wait is finally over for rural health care officials and advocates across the U.S., who have been "hotly debating" how much of the newly formed $50 billion Rural Health Transformation Program their state will receive. The Centers for Medicare & Medicaid Services announced their awards last week.

The five-year program divides half of the $10 billion-per-year distribution equally among the states; however, the division of the remaining $25 billion was "determined by the CMS based on how well the states’ pitches met goals of strengthening rural health prevention, standing up sustainable access, developing a rural workforce and introducing innovative care delivery and technology," reports Dave Muoio of Fierce Healthcare. 

CMS paired its award listing with an abstract of each state's application. "Only a subset of states have so far opted to make their full applications available to the public," Muoio explains. The complete list of state funding awards is here.

All 50 states received awards from the second half of the funds, with Texas and Alaska garnering the largest awards, and New Jersey and Connecticut receiving the smallest funding amounts. Some factors involved in the selective division included each state's rural population and the number of residents living in frontier regions.

While rural hospitals and providers have voiced support for the program, many are cautious about how much the new funding can do to balance "the nearly $1 trillion of nationwide Medicaid cuts expected over the coming decade," Muoio adds.

Last month, CMS announced the formation of a new office to manage the Rural Transformation Program and its funds.

A Medicare pilot program will use artificial intelligence for prior authorizations. Doctors and lawmakers are alarmed.

Some prior authorization requests are already decided
by artificial intelligence. (Adobe Stock photo) 

A Medicare pilot program that allows private companies to use artificial intelligence to approve or deny medical care requested by their members has some doctors and lawmakers worried. Companies included in the pilot would get paid, "based on how much money they save Medicare by denying approvals," reports Anna Claire Vollers of Stateline.

The pilot, known as the Wasteful and Inappropriate Services Reduction (WISeR) Model, will launch after Jan. 1 in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. WISeR is more likely to impact health care treatments for rural Americans in those states because rural populations often skew older and sicker than their suburban and urban counterparts.

At its core, the WISeR model effectively introduces a prior authorization process into traditional Medicare. Prior authorization is already unpopular with many patients and doctors because it requires members or medical providers to request an insurance company's approval for certain treatments or medications before proceeding.

While some Medicare Advantage and private insurance companies have already deployed AI into some of their prior authorization processes, its use has "attracted intense criticism, legislative action by state and federal lawmakers, federal investigations and class-action lawsuits," Vollers explains. "It’s been linked to bad health outcomes. Dozens of states have passed legislation in recent years to regulate the practice."

The new program has "alarmed many physicians and advocates in the affected states," Vollers reports. In practice, the prior authorization process can create obstacles to care by requiring physicians to spend hours fighting with an insurance company to justify the care they believe their patient needs. At times, medical providers may avoid treatments that would be best because an insurance company is likely to deny them, at least initially.

Last month, congressional representatives from several states "introduced a bill to repeal the WISeR model. It’s currently in committee," Vollers reports. The program is scheduled to run from 2026 to 2031.

While details of rural health transformation requests aren't available yet, some states are sharing their information

KFF News RHTP tracking map as of Dec. 2. Click to enlarge.

The newly formed federal Rural Health Transformation Program has $50 billion to distribute to states that met its Nov. 5 application deadline; however, a complete picture of which states applied and what they asked for isn't clear because the Centers for Medicare & Medicaid Services have "declined to publicly release the applications," report Sarah Jane Tribble and Arielle Zionts of KFF Health News.

CMS said it isn't allowed to "release grant applications to the public during the merit review process,” KFF News reports. "They've pledged to announce the allocations by Dec. 31."

RHTP was passed as part of the One Big Beautiful Bill Act in July, which drastically cut Medicaid spending and will disproportionately impact rural areas. But RHTP can't be used to "bail out" rural hospitals or clinics. KFF News explains, "The money [must] be spent on transformational ideas."

Although CMS isn't sharing application details, some states have been transparent about their applications. According to the article, a health strategy team at Princeton University tasked with tracking state application summaries found "themes including expansion of home-based and mobile services, increased use of technology, and workforce development initiatives . . ."

KFF Health News is collecting state-by-state application materials and adding them to its mapped repository, which will be updated as information arrives. 

A rural hospital in California closes after federal officials strip 'critical access' designation it has held since 2000

Glenn Medical Center in Willows, California 
(Glenn Medical Center photo)

After more than 70 years of serving its rural community in Willows, California, Glenn Medical Center closed its doors following the loss of its "critical access" designation, which had allowed the hospital to receive higher federal reimbursements that helped it remain open.

To qualify as a "critical access" hospital, a medical center needs to be at least 35 miles from the next closest hospital. Glenn Medical Center was 32 miles from "the nearest neighboring hospital under a route mapped by federal officials," reports Jessica Garrison of the L.A. Times. "Though that distance hasn’t changed, the federal government has now decided to enforce its rules." The hospital was awarded its critical access status in 2000.

The loss of Glenn Medical Center leaves the surrounding farming community without emergency care, "eliminates 150 jobs and puts rural residents at risk of preventable deaths," Garrison writes.

Rural hospitals across the state are already at risk of closure. Peggy Wheeler, vice president of policy of the California Hospital Association, told Garrison, "It’s like the beginning of a tidal wave. I’m concerned we will lose several rural hospitals, and then the whole system may be at risk.”

Before Glenn Medical Center's designation was stripped, Glenn County officials and hospital administrators worked for months to persuade federal officials to grant an exception.

Now that the hospital is closed, many community members fear what will happen to older residents in need of immediate care, injured farm workers or victims of car accidents along nearby Interstate 5. Glenn County Supervisor Monica Rossman told Garrison, "People are going to die."

Rural hospitals in Arkansas find different ways to stay open and still serve their communities

Rural hospitals, represented by green dots, stretch across mid- to southern Arkansas counties. 

Rural hospitals in Arkansas continue to explore the best ways to serve their communities despite severe financial struggles. Some medical centers have found success by ending inpatient care in exchange for more Medicare dollars, while others keep their doors open by opting for other designations to continue providing vital care, such as inpatient stays, reports Tess Vrbin of The Arkansas Advocate. According to a 2023 University of Arkansas review, roughly 41% of Arkansas residents live in rural areas.

Two years ago, DeWitt Hospital and Nursing Home was in financial straits and CEO Brian Miller chose to convert it into a "rural emergency hospital, which draws more federal funds to rural hospitals if they reduce or eliminate inpatient services and focus on emergency and outpatient treatment," Vrbin writes.

Beyond higher Medicare payments, the switch helped DeWitt lower costs while adding income from outpatient services, such as cardiology and wound care. The hospital is one of five Arkansas hospitals to sign up for the emergency rural designation.

But converting to an emergency triage-type care model doesn't work for every rural community. The Southwest Arkansas Regional Medical Center in Hope will not apply for rural emergency status because inpatient stays are needed for residents in surrounding counties. Its chief administrative officer, Shelby Brown, told Vrbin, "We want to be able to, if we need to admit someone, to put them in our hospital so they can stay home locally."

Instead of opting to convert to a rural emergency hospital, Southwest Arkansas Regional applied for and received approval to become "a critical access hospital, a federal designation for facilities located no fewer than 35 miles from other hospitals and maintaining no more than 25 beds," Vrbin explains. "Medicare subsidizes critical access hospitals for inpatient treatment of Medicare recipients."

For many rural hospitals in Arkansas, the choice between ending certain types of patient care or possible closure is difficult. Brown told the Advocate, "The big scheme of rural health in the state of Arkansas is in a crisis mode. . . . I would always think it’s better to have a rural emergency hospital versus no hospital.”

Hundreds of rural hospitals are 'vulnerable to closure' and 46% operate in the red, new report finds

Many rural hospitals have dropped some type of
inpatient care to save money. (Adobe Stock photo)

Despite some limited improvements, the newest statistics on rural hospitals from healthcare advisory firm Chartis are startling. "The group’s latest report on the state of rural healthcare providers found that 46% of rural hospitals are operating at a loss while 432 hospitals are deemed 'vulnerable to closure,'" reports Dave Muoio for Fierce Healthcare. The 2024 report from Chartis "outlined 50% of rural hospitals operating in the red and 418 hospitals at risk of closure."

A rural hospital's median operating margin and Medicaid expansion status are among the factors Chartis used to determine financial health. "Nationwide median operating margin for rural hospitals currently sits at 1%, with 16 states having medians below 0%," Muoio writes. "In the 10 non-Medicaid expansion states, which hold 30% of all rural hospitals, 53% of rural hospitals [operate] in the red, with a median operating margin of -1.5%."

Rural hospitals that aren't in the red have often shuttered their obstetric units and shed inpatient care or other services to stay solvent. "Inpatient care access has ended across 182 rural communities since 2010, due to either closures or transitions," Muoio explains. "Between 2011 and 2023, 293 rural hospitals stopped offering obstetrics services. . . . A similar trend was evident regarding chemotherapy. . . from 2014 to 2023, 424 rural hospitals ended the service."

The report highlighted the "key hurdles for rural hospitals, such as a 2% Medicare reimbursement cut that 'will cost rural hospitals more than $509 million this year and result in over 8,000 jobs lost,'" Muoio reports. "Chartis’ dire national snapshot comes shortly after a Wipfli survey found sparks of optimism among rural healthcare organization leaders. . . .[But] some of their views may have already changed in light of recent weeks’ political developments."

Three ways the new administration could help rural America meet its challenges

Helping younger farmers helps local land stay
locally owned. (Abobe Stock photo)

Seeking a voice and change small-town America needs, many rural voters rallied for President Donald Trump to return to the White House. Now that he's back in the Oval Office, there are three ways his administration could work with Congress to help rural America face its challenges, write Randolph Hubach and Cody Mullen for The Conversation.

Health care is a good place to start.
Rural Americans are more likely to receive Medicaid or Medicare health care coverage and more vulnerable to negative impacts from policy or funding changes. "Funding from those federal programs affects rural hospitals, and rural hospitals are struggling," Hubach and Mullen explain. "Nearly half of rural hospitals operate in the red today, and over 170 rural hospitals have closed since 2010."

They recommend government funding continue for the Low-volume Hospital Adjustment Act and the rural emergency hospital model because both programs address rural health care providers' financial needs. Additional support and expansion of rural telehealth services is also needed.

Help small towns address affordable housing.
Like much of the country, rural communities lack affordable housing. To help small towns create housing solutions, the new administration should support the "bipartisan Neighborhood Homes Investment Act, which calls for creating a new federal tax credit to spur the development and renovation of family housing in distressed urban, suburban and rural neighborhoods," Hubach and Mullen add. "The Section 502 Direct Loan Program through the Department of Agriculture could be expanded with additional funding to enable more people to receive subsidized mortgages."

Keep local lands locally owned.
Rural businesses and landowners tend to care about the communities they call home. Congress could support rural land ownership through the "proposed Farm Transitions Act [that] would establish a commission on farm transitions to study issues that affect locally owned farms and provide recommendations to help transition agricultural operations to the next generation of farmers and ranchers," Hubach and Mullen add.

The Trump administration also could continue assistance for young farmers. "About 30% of farmers have been in business for less than 10 years, and many of them rent the land they farm," they write. "Programs such as USDA’s farm loan programs and the Beginning Farmer and Rancher Development Program help support local land purchases and could be improved to identify and eliminate barriers that communities face."

Medicare will save billions from its first-ever drug price negotiations with pharmaceutical companies

The negotiated prices will apply in 2026.
(Adobe Stock photo)

The first-ever talks between Medicare and pharmaceutical companies have yielded some positive change for Medicare expenditures, but how much older Americans will save remains uncertain. "The federal government released the new prices it will pay for 10 prescription drugs," reports Jared S. Hopkins of The Wall Street Journal. "The drugs, for serious conditions including cancer, diabetes and blood clots cost the government more than $50 billion a year altogether. . . . [But] they might not translate into much savings for many seniors."

The talks were Medicare's first foray using its massive consumer base to tamp down drug prices. "Lowering drug prices through negotiations is a milestone in years of efforts to give Medicare, the country’s biggest purchaser of prescription medicines, a power that private health plans have long deployed to keep a lid on rising drug costs," Hopkins explains. "It follows other new government measures tackling high drug prices, such as a $35 cap on how much Medicare members pay out of pocket for insulin."

Here are a few of the newly negotiated drug prices for a month’s supply compared to Medicare's 2023 list price for a 30-day supply. To read the full list, click here.

Eliquis, a blood thinner from Bristol-Myers Squibb and Pfizer: $231, down from $521;
Enbrel, an arthritis drug from Amgen: $2,355, down from $7,106;
Jardiance, a diabetes drug from Eli Lilly and Boehringer Ingelheim: $197, down from $573;
Stelara, a psoriasis drug from J&J: $4,695, down from $13,836;
Xarelto, a blood thinner from J&J: $197, down from $517.

Medicare's new prices will start in 2026. Anna Anderson-Cook and Richard G. Frank of Brookings report, "Using publicly-available data, estimate savings consistent with CMS reporting, find that 51.4% of the estimated savings ($3.28 billion) is accounted for by 3 drugs. Penn reports, "The negotiations will save nearly $100 billion by 2031, the Congressional Budget Office estimated."

After its hospital closed, N.C. county works to be the first in the nation to reopen its hospital under ER-only designation

Martin General closed in 2023. (WITN TV photo)

After serving rural Martin County, N.C., for 73 years, Martin General hospital closed its doors, leaving the community's 22,000 residents without a medical care center. Like many rural hospitals across the United States, Martin General had faced shrinking profits and bankruptcy before it closed. But that's not the end of Martin General's story, reports Jaymie Baxley of NC HealthNews. "The county [is working] on a complex plan to resurrect Martin General — a plan that, if successful, could become a blueprint for other rural communities where hospitals have closed."

To make reopening possible, Martin County and hospital officials applied to change Martin General's designation from a full-service hospital to a 'rural emergency hospital,' which means the hospital would offer 24/7 emergency care but give up its inpatient services. Baxley explains, "In exchange, the hospital would receive millions in annual funding from the federal government. . . and be eligible for increased reimbursement rates for some outpatient services covered by Medicare."

But Martin General faced an unusual hurdle to becoming a rural emergency hospital -- it had already closed. Hospitals that had successfully made the switch did so while they were still open, Baxley reports. "Officials in Martin County, however, believe the hospital [could be] reopened using the rural emergency model — something that had not been attempted anywhere else in the nation. . . . Earlier this year, the Centers for Medicare and Medicaid Services confirmed that Martin General could reopen as a rural emergency hospital, clearing the first and arguably most important hurdle in the county’s path."

Martin General's status as a "closed hospital" also means state laws present reopening obstacles. Ben Eisner, interim Martin County manager, told Baxley, “As far as we can tell, this is really the first such situation in the country. Trying to navigate that has certainly been tricky. It’s taken us a number of months to work through some of the regulatory issues of opening a closed hospital as a rural emergency hospital.”

At present, Martin General's resurrection remains a work in progress. "In addition to being the first hospital in the nation to reopen as a rural emergency hospital, Martin General would be the first hospital in the state to receive the designation," Baxley writes. "Because the program is not open to facilities that closed before 2023, it cannot be used to bring back the state’s other shuttered hospitals. . . . But Martin County’s experience could provide a road map for other rural communities facing a similar situation in the future."

Half of rural hospitals lose money; consultancy estimates 418 could close, citing Medicare Advantage as big issue

Map by Chartis Center for Rural Health, labeled by The Rural Blog

Rural hospitals are in more trouble than ever, and 418 of them are “vulnerable to closure,” according to a study of their finances by Chartis, a Chicago-based health-care consultancy that specializes in tracking the business of rural health. (Here's its list of top 100 rural and community hospitals.)

The Chartis Center for Rural Health says rural hospitals are entering "a startling new phase of this crisis as rural hospitals fall deeper into the red, 'care deserts' widen throughout rural communities, and the increasing penetration of Medicare Advantage could further disrupt rural hospital revenue."

The top warning signal cited in the study is that half of rural hospitals are losing money, up from 43 percent a year ago. That news is especially bad for independent rural hospitals, 55% of which are in the red, while only 42% of rural hospitals affiliated with groups are operating at a loss. "Nearly 60% of rural hospitals are now affiliated with a health system," Chartis reports.

Most people on Medicare now have Medicare Advantage, private insurance plans that get lump sums from Medicare to cover members and look for ways to attract customers while limiting claims. "Medicare Advantage now accounts for 35% of all Medicare-eligible patients in rural communities," Chartis reports, saying Advantage plans' share of rural residents has risen 48% since 2019. 

Chartis map, labeled by The Rural Blog; click to enlarge

That's a problem for rural hospitals designated as "critical access" because Medicare Advantage plans' net reimbursement to such hospitals "is often lower for similar services than that of traditional Medicare because Medicare Advantage does not follow cost-based reimbursement" as traditional Medicare does for such hospitals, Chartis reports. Insurance companies negotiate those rates with hospitals, and in many rural areas, hospitals are at a negotiating disadvantage because few insurers operate in their service areas.

Also, "Medicare Advantage may not cover all the services traditional Medicare does, including swing beds, which provide skilled nursing care for patients and are often a strong source of revenue stability for rural hospitals," Chartis notes. "Rural providers may not be equipped to efficiently navigate administrative requirements for payment introduced by Medicare Advantage, such as prior authorizations, which can lead to increased denials."

Since 2010, "167 rural hospitals have either closed or converted to a model that excludes inpatient care," Chartis says. The firm says its estimate that 418 are “vulnerable to closure” is based on "a new, expanded statistical analysis" of their finances, gleaned from cost reports they file with Medicare.

Dialysis centers have increasingly moved into rural areas, but travel still remains an obstacle, a new study finds

The treatment schedule ESRD requires means most
patients can't work. (Photo by Annie Spratt, Unsplash)

Once Medicare and Medicaid began covering dialysis costs, for-profit centers started opening in areas where larger clusters of patients live. A new study shows dialysis centers have increasingly moved into rural areas, reports Liz Carey of The Daily Yonder. Jan Probst, a researcher at the Rural and Minority Health Research Center in South Carolina, conducted a study that "looked at where dialysis centers are located and who lives in those areas, then compared the findings to similar past studies."

Dialysis cleans the blood, a job kidney organs usually do, but dialysis is used when kidneys fail due to end-stage renal disease. ESRD can be "caused by diabetes and high blood pressure, among other things," Carey writes. "Patients come to dialysis facilities and spend hours hooked up to machines that remove the blood from their body, filter it through an artificial kidney, and return it to the body."

In general, Probst's study showed that "rural residents have to travel farther to get to dialysis treatment facilities," Carey writes. "This isn't unexpected, she said. In the rural Southeast and Southwest, greater distances between communities mean those residents have to travel farther to get to their treatments. Rural residents, on average, have to travel just over 14 miles to get to the nearest facility. In contrast, urban residents live about 4.5 miles from the nearest dialysis center."

While rural residents still travel further for the expensive treatment, Probst notes her new study shows "a vast improvement from the last time Probst did the same research in 2013. In that study, rural residents had to travel about 40 miles to get to a dialysis facility," Carey writes. "The increase in access to dialysis centers isn't solely due to need, Probst said. Since her 2013 study, how dialysis is funded has changed. Now, federal policy requires Medicare and Medicaid to pay for dialysis treatments. And once Medicaid and Medicare guaranteed payment, Probst said, the market responded."

Even though most rural residents with ESRD may live closer to dialysis centers, the treatment is needed three times a week, and centers often don't offer evening or weekend care. Carey reports, "The burden dialysis places on rural patients would make maintaining any kind of job extremely difficult, Probst said." Probst told her: "I suspect that for most of these folks that [working] is not feasible, and they probably also have multiple things to deal with. They've lost their kidneys, but they still have to deal with their dialysis. There's a lot going on."

Proposed new rules for nursing homes have sparked warnings and fear; rural residents are the most vulnerable

National Cancer Institute photo, Unsplash

The Centers for Medicare and Medicaid's new staffing mandates were met with alarm and fear, with descriptions including 'a disaster,' 'insanity', and 'catastrophic.' The Biden Administration's "proposed federal staffing mandate will be impossible for the nation's nursing homes to meet, limiting access to care for our seniors," reports The American Health Care Association. "CMS released the one-size-fits-all mandate earlier this year, despite its own study finding no level of staffing guarantees quality of care."

The angry reaction and warnings are particularly problematic for rural Americans. "As nursing home closures continue across the country, 'nursing home deserts' are expanding, and the proposed federal staffing mandate is expected to exacerbate the problem," reports Amy Stulick of Skilled Nursing News. "This is despite attempts to make the potential policy change easier for providers in rural markets, which are especially vulnerable to access issues. Operators in these areas point to the 24-hour RN requirement as being especially devastating."

Finding nurses, let alone 24-hour nurses, is impossible in certain areas. Nate Schema, CEO of the Evangelical Lutheran Good Samaritan Society, "says the organization's facilities located in 'deep rural communities' will struggle the most with the 24-hour RN rule," Stulick writes. "In communities like Bloomfield, Nebraska, pop. 1,000, or Miller, South Dakota, pop. 1, 300, Schema isn't sure where Good Samaritan will find even six RNs; the Miller facility hasn't had a night nurse for upward of three years."

"The ability to have a nursing home open in a small town is getting more difficult because of the disparity between Medicaid reimbursement and overall costs, says Accura HealthCare CEO Ted LeNeave," Stulick reports. "Accura operates 34 communities across Iowa, Minnesota, Nebraska and South Dakota." LeNeave told Stulick: "The provider relief fund helped to mask how bad those problems were. Once that cash dried up, buildings started closing. This concept of a nursing home desert is an area where residents need nursing home care, but there's no access to them. Then they have to drive 45 minutes to an hour to be somewhere else."

Michael Beal, CEO of Care Initiatives, told Stulick, "It doesn't matter if it's 5, 10 or 15 years, if there's no additional reimbursement, it's just a timing question on when that will affect [rural operators]; it just kicks the can down the road." Stulick reports: "Beal added that the suggested rule of 'adding that an arbitrary number of staff hours per resident day without a reimbursement mechanism, and the ability to actually hire staff puts rural operators in an 'untenable situation.'"

When to get which vaccine and how to get insurance to pay for it has some Americans ditching vaccines

Illustration by Molly Ferguson, Stat

If it's too hard to understand or to get done, many people will opt out -- as is the case with adults attempting to get vaccines.

"Alison Buttenheim was floored by a sign she saw in her doctor’s office when she went to get the first jab of the two-dose shingles vaccine to protect her against painful flare-ups of varicella zoster," reports Helen Braswell of Stat. "The notice read: 'Medicare patients cannot receive Tdap or zoster vaccines here. They need to obtain [them] at their pharmacy. If they receive it here, they need to pay out of pocket.' In this instance, patients could receive vaccines covered by Medicare as treatment, but not as a preventative measure. For instance, if a person stepped on a nail, Medicare would pay for their tetanus shot; however, if a patient is getting a tetanus booster to maintain protection, Medicare would not cover it.

Buttenheim, a professor of nursing at the University of Pennsylvania who studies vaccine acceptance and hesitancy, "knows that any amount of difficulty in the immunization process can deter people from getting vaccinated. She couldn’t believe her eyes," Branswell explains. "To stay abreast of what to get and when and where to get it almost requires would-be vaccine recipients to have advanced degrees. Buttenheim recently found herself shelling out $160 for her latest Covid booster. She told Branswell, "We’re absolutely making it too hard."

Branswell reports, "Some of that may be due to vaccine hesitancy but more of it is likely due to the sheer difficulty of knowing what to get, when to get it, and how to get insurance coverage for the various shots, said Saad Omer, a vaccine expert who is dean of the Peter O’Donnell Jr. School of Public Health at the University of Texas Southwestern." Omer told Branswell: “Beyond the cacophony of pro-vaccine and anti-vaccine arguments on X (formerly know as Twitter), most of the country doesn’t actively think about vaccines, period."

How rural hospitals are fighting Medicare Advantage

Medicare Advantage plans may offer more benefits but also
have rules that can limit patients' choices. (Anthem website)

St. Charles Health System in central Oregon has "threatened to cut ties with all Medicare Advantage plans next year, a move that would leave an estimated 26,000 local beneficiaries without access to a hospital less than 100 miles away," reports Nona Tepper for Modern Healthcare.

"A program intended to promote seamless and higher quality care has instead become a fragmented patchwork of administrative delays, denials and frustrations," St. Charles CEO Steve Gordon said in a news release last month.

Tepper reports, "Health systems nationwide appear to share Gordon's consternation, especially those similarly located in rural areas. Rural healthcare providers tend to be disproportionately affected by factors such as reimbursement cuts or denied and delayed payments from Medicare Advantage plans because Medicare enrollees make up most of their patient populations. Cutting off Medicare Advantage plans, or at least declaring that to be a possibility, is a response to the growing market power these carriers have, especially over rural providers.

According to Tepper, "Rural Medicare Advantage enrollment is growing faster than overall enrollment: Since 2010, the share of rural beneficiaries who choose private plans over the traditional program has more than quadrupled, to 40% from 11%, according to KFF survey results published this month.

"Among the 58 publicly known contract disputes between insurers and providers this year, 35—more than half—involved Medicare Advantage carriers, according to data compiled by FTI Consulting. 

"Most conflicts center on how health insurance companies do business more than on reimbursements, said FTI Consulting Managing Director Adam Broder."

Tepper reports: "At Aspirus Health, some Medicare Advantage insurers deny as many as 35% of claims, said Matthew Heywood, CEO of the Wausau, Wisconsin-based nonprofit health system. In response, the 17-hospital chain is renegotiating contracts to include provisions regarding prior authorizations and claims processing times, he said."

Proposal for more nursing-home staff seen as unattainable by many owners; resident advocates say it's not enough

Nursing homes may not be ready for 'tsunami' of baby boomers.
(Photo by G.A. Pflueger, Unsplash)

Nursing homes have struggled for decades to find a sustainable business model that provides optimal staffing numbers for resident care. Now federal officials have released "a proposed rule requiring the nation’s nursing homes to hire minimum numbers of front-line caregivers, a long-anticipated response to decades of complaints about neglect and abuse in an industry that critics say is unprepared for the tsunami of seniors heading its way from the baby boom," reports Christopher Rowland of The Washinton Post.

The Centers for Medicare and Medicaid Services proposed "minimum nurse staffing standards . . . per resident for registered nurses and . . . nurse aides," as well as a requirement to have a registered nurse at the nursing home around the clock. Many industry stakeholders consider the proposal futile. Rowland explains, "Without a supply of prospective workers, it will be impossible to meet the requirements of minimum staffing, the industry has argued. They also contend that Medicaid reimbursement rates need to be significantly increased if more workers are required in facilities." Nathan Schema, president and chief executive officer of the Evangelical Lutheran Good Samaritan Society, which operates a large chain of nonprofit nursing homes, told Rowland: "I just can’t understand how CMS is effectively trying to fix the roof while the house is on fire. It’s the beginning of the end for small-town nursing homes."

Rowland adds, "A fifth of nursing homes would have to hire registered nurses to meet the requirement, the government estimates." LeadingAge, the largest association for nonprofit nursing homes, told USA Today that the proposed regulation would be impossible for many nursing homes to meet. “There are simply no people to hire—especially nurses,” said Katie Smith Sloan, the group's president and CEO. “America’s under-funded, long-ignored long-term care sector is in a workforce crisis.” Sloan said nursing homes would have to “reduce admissions or even close” if the rule takes effect.

"While the industry reacted negatively to the proposed rule’s release, the guidelines also disappointed advocates for better treatment of residents in chronically short-staffed nursing homes, who contend the rule does not go far enough and enshrines substandard levels of care," Rowland reports. "Advocates for better quality care in nursing homes say the industry’s high staff turnover rates point to the true problem: insufficient pay and poor working conditions."

Feds propose the first minimum-staffing rules for nursing homes, and they are weaker than the industry expected

Federal officials' proposed minimum standards for nursing-home staffing are weaker than expected, Bridget Early reports for Inside Health Policy.

The nursing-home industry had anticipated a proposal for about 4.1 hours of employee work time per resident day, meaning that a home with 25 residents would require 18 staffers (times 4.1 hours per resident day = 175 hours per week, divided by 40 hours per week = 17.9 employees).

Instead, Early reports, "The minimum staffing scenarios assessed in the report ranged from 3.3 HPRD to 3.8 HPRD," which would call for 14.4 to 16.625 employees to cover 25 residents.

The regulation could have major implications for rural nursing homes, which generally have more difficulty recruting and retaining staff than those in cities.

The regulation, proposed by the Centers for Medicare and Medicaid Services, "cleared the White House Office of Management and Budget on Tuesday, Aug. 29, the same day a CMS study underpinning the rule was leaked and created a firestorm among stakeholders," Early reports. "The White House budget office also canceled its two remaining stakeholder meetings on the issue in the wake of the leak. The proposed rule had been pending at OMB since May 30. The two meetings were scheduled for the first and second weeks of September. The meetings were requested by the Organization of Nurse Leaders and the Association of Jewish Aging Services."

Early notes, "The nursing-home industry has lobbied hard against staffing minimums and has called for a White House event to explore alternatives, but patient advocates have backed staffing minimums."

Advocacy group says over 30% of rural hospitals are at risk of closing, many immediately; publishes financial data

Maps from Center for Healthcare Quality and Payment Reform; to enlarge, click on it.

More than 30% of the nation's rural hospitals are at risk of closing, partly because special financial aid they got from the federal government during the pandemic has ended, according to the latest analysis of their 2020-22 Medicare cost reports by the Center for Healthcare Quality and Payment Reform, a private group.

New York, Alabama and Mississippi have "the highest percentage of rural hospitals at risk of immediate closure," reports Devna Bose of Mississippi Today. In New York, 43% of rural hospitals (22) are considered at risk; it's 37% (19) in Alabama and 34% (25) in Mississippi. The report has numbers and percentages for each state.

A map with figures for each hospital is here (example screenshot below). The group said its analysis was based on examinations of hospitals' financial reports, with the main risk factors being on negative operating margins, losses on patient services and low financial reserves.

Rural hospitals' troubles are often blamed on low rates of reimbursement for Medicare and Medicaid patients, which are a majority of their admissions, but the group says "losses on private insurance patients are the biggest cause of their overall losses."

Here's part of the map that has data for hospitals in 2020-22, highlighting one in Kentucky:

Screenshot of map by Center for Healthcare Quality and Payment Reform at ruralhospitals.chqpr.org