The Affordable Connectivity Program helped millions of rural and tribal Americans gain Internet access -- now what?

ACP helped rural and tribal resident bridge the
digital divide. (Adobe Stock photo)

During the pandemic years, rural and tribal communities learned to rely on affordable internet services provided in part by the federal Affordable Connectivity Program. The more dependable and budget-friendly connection helped residents use the web for telehealth appointments, online ordering and remote learning, reports Sarah Jane Tribble of KFF Health News. In May, the ACP ran out of money, and many residents are considering what they may have to sacrifice to keep reliable internet service without the subsidy.

Although the ACP eventually enrolled around 23 million low-income households -- or one in six American families -- its funding was not renewed. "Sen. John Thune (R-S.D.) challenged an effort to continue funding the program, saying during a commerce committee hearing that the program needed to be revamped," Tribble writes. Thune claimed that ACP did not reach those that "truly needed it."

Despite a hive of legislative workers trying to iron out the program's shortcomings, funding for ACP ended; however, the Biden administration "announced that more than a dozen companies — including AT&T, Verizon, and Comcast — would offer low-cost plans to ACP enrollees," Tribble reports. "The administration said those plans could affect as many as 10 million households."

Without the ACP, many rural families may be unable to bridge the digital divide. "According to a survey of participants released by the Federal Communications Commission, more than two-thirds of households had inconsistent or no internet connection before enrolling in the program," Tribble explains. "The FCC said that ending the program will affect about 3.4 million rural and more than 300,000 households in tribal areas."

Feds offer rural hospitals 'excruciating choice' of a lot more money in exchange for becoming a glorified first-aid station

Rural hospitals are a lifeline for 46 million Americans, yet an increasing number of them are closing, a situation that has prompted the federal government to initiate a new program that will offer a huge infusion of cash to more than 1,700 of them, but comes with the condition that they must end all inpatient care, "an excruciating choice," Emily Baumgaertner reports for The New York Times.

Any hospital that accepts this deal would become a "rural emergency hospital," allowing it to get monthly payments totaling more than $3 million a year and get higher Medicare reimbursements.  For many, that would be a game-changer "that would not only keep them open but allow them to expand services and staff," Baumgaertner writes, but "In return, they must commit to discharging or transferring their patients to bigger hospitals within 24 hours." 

The rationale: "Many rural hospitals can no longer afford to offer inpatient care," she writes. "A rural closure is often preceded by a decline in volume, according to a congressional report, and empty beds can drain the hospital’s ability to provide outpatient services that the community needs."

Harold Miller, president of the nonprofit Center for Healthcare Quality and Payment Reform, told the Times: “On one hand, you have a massive incentive, a ‘Wow!’ kind of deal that feels impossible to turn down. But it’s based on this longstanding myth that they’ve been forced to deliver inpatient services — not that their communities need those services to survive.”

Critics of the plan told the Times that officials behind the new program are out of touch with the difficulties of transferring patients, noting that bigger hospitals are increasingly unwilling to accept transferred patients, particularly from small field hospitals that are unaffiliated with their own systems. Add to that, they pointed to other challenges, including blizzards, downed cattle fences and mountain pass roads that are closed for months at a time. 

She also tells stories of how rural hospitals have saved patients when the hospital couldn't find another one to take the transfer and how rural hospitals routinely care for patients with chronic conditions like congestive heart failure or when they need rehabilitations. In essence, keeping these patients closer to home for their extended care. 

“I really want to give this policy a chance to work well,” Katy Kozhimannil, director of the University of Minnesota Rural Health Research Center, told the Times. But gambling with transfers could mean that “some of the most extremely remote and marginalized communities could end up with no care at all — and that’s what we were trying to avoid in the first place.”

More than 180 rural hospitals have closed in the United States since 2005, according to a recent analysis, with a record 19 closings in 2020 alone. In 2021, the number plummeted to just two, but the more than $15 billion in pandemic-era federal aid was injected into rural hospitals to keep them open will mostly expire Dec. 31.

"Over 600 rural hospitals — 30 percent of the total — are at risk of shuttering," Baumgaertner writes. "More than 200 could close within three years, according to a study by the Center for Healthcare Quality and Payment Reform. In 10 states, at least 40 percent of rural hospitals are in danger: In Kansas, 16 could close within three years; in Mississippi, 24."

The office of Senator Charles E. Grassley, Republican of Iowa, who is one of the lawmakers behind the program, said in a November statement, “The goal is to preserve patient access to emergency medical care in rural areas that can no longer support a fully operational inpatient hospital.” There are no exceptions for maternity hospitals. The new option becomes available Jan. 1.

'Digital divide' between rural and urban shows no sign of disappearing as broadband gets faster

Photo: bradselectronics.com

The "digital divide" between rural and urban areas has not disappeared despite ever-improving technology. The latest data from the Federal Communications Commission and the National Telecommunications and Information Administration show that only 55 percent of people living in rural areas have access to broadband internet service, while 94 percent of their urban counterparts do.

Why does it matter? Broadband adoption can help improve the economy in rural areas, including increasing income, lowering unemployment rates and creating jobs, Brian Whitacre, associate professor and Extension economist at Oklahoma State University, wrote in USA Today.

Lack of access to a fast internet connection at school and at home can also set children living in poor rural areas up for failure. The Rural Blog previously reported that these children often suffer with important life skills that require online fluency: college applications, research for papers and job searches.

Technology continues to improve, allowing existing wiring to carry heavier loads of data. The federal government has historically tried to expand infrastructure that would allow for broadband access to rural communities. The "Connect America Fund" offered $10 billion in subsidies to the nation's largest telecommunication companies to offer service to more than 4 million un-served homes and businesses in 2015.

What classifies as "broadband" is determined by the FCC, and it changes fairly regularly as technology evolves. In the early 2000s, the FCC defined broadband connections as those that could transfer data at a speed of 200 kilobytes per second (kbps) in at least one direction, either downloading or uploading. That was about four times faster than historical dial-up modems (56 kbps).

In 2010, the FCC required connections to be five times faster still to be considered broadband. The minimum downstream (downloading) speed increased to 4 megabits per second (mbps), with at least 1 mbps upstream (uploading). Companies receiving Connect America Funds have to provide at least 10 mbps downstream and 1 upstream. But in 2015, the FCC again upgraded its broadband requirement to 25 mbps downstream and 3 mbps upstream, meaning that federal dollars funded service that already falls short of current requirements at the time of implementation.

Whitacre predicts the threshold will continue to increase, and rural areas will require the most work to reach it and stay compliant; their existing bandwidth is generally slower than in urban areas. Only 75 percent of rural Americans have access to fixed (not mobile) connections of at least 10 mbps download speeds, compared to 98 percent of urban residents, Whitacre notes. Only 61 percent of rural residents meet the current 25 mbps threshold for any type of technology, compared to 94 percent of city dwellers.

A major obstacle to rural broadband access is cost. It's more efficient for companies to install lines in high population areas because there are far more people to pay for use of those lines. Installing lines in rural areas is costly, and because there are fewer potential customers per square mile, they don't turn a profit as readily as those in cities.

Even improving existing wires in rural areas can be expensive. Fiber optic cable is used in new installs. In areas still served by older copper wires, though, sending data at high speeds for long distances can be a problem. Signals degrade after about three miles. To get data traveling longer distances to and through rural areas, companies must install signal-amplifying equipment called "access multipliers," which add to the cost of serving rural areas, Whitacre writes.

However, rural broadband advocates have had some good news the past couple of years with the continuing development of the Connect America Fund. The FCC set up several "Rural Broadband Experiments" in 2015, with 14 projects ongoing (10 fiber and four wireless). Whitacre said that he expects these experiments to provide some insight into the technological, administrative and logistical issues associated with funding rural broadband.

Even if rural broadband infrastructure were exactly the same as in cities, there would still be a "digital divide" in adoption rates, Whitacre noted because rural populations are older, less educated and have lower income.

Hospital on Ky.-Tenn. border illustrates the value of Medicaid expansion to rural health-care facilities

Sperling's Best Places map

Jellico Community Hospital, on the Kentucky border in the Cumberland Mountains of Tennessee, was taken over by Texas-based Community Hospital Corp. last May after the previous owners wanted out because they were losing "millions a year," Harris Meyer reports for Modern Healthcare. Now, jobs are safe and the economically depressed community can hold onto the hope that its hospital will survive.

Losing money is all too common in rural hospitals, especially in states like Tennessee that haven't expanded Medicaid, but about half of the hospital's patients are from Kentucky, which did expand Medicaid, and it operates a clinic in the seat of the Kentucky county Jellico borders. "The hospital's administrators, doctors and nurses all say it's easier to get testing and specialty care for Kentucky Medicaid patients," Meyer writes.

The 31 states that have expanded Medicaid have been able to "shore up finances" in many of their rural hospitals, Meyer writes, but others have not fared so well. Nationwide, more than 50 rural hospitals have closed in the past six years, and nearly 300 more are in deep financial trouble, according to the National Rural Health Association. In Tennessee, Meyer notes that three hospitals have closed since 2013 and a fourth will close in May.

Meyer notes that the Jellico hospital still has big problems. It serves an area where good-paying jobs with health benefits have dwindled, only 10 percent of the population has private health insurance, residents have higher-than-average rates of disease, and there is rampant obesity and drug abuse.

The 54-bed hospital with its staff of 232 is the community's largest employer, as many rural hospitals are. The mayor emphasized how important it is for the hospital to survive, telling Meyer that new businesses will often not consider moving to an area that doesn't have one. (Read more)

National Rural Health Day is Thursday; webinars available on a variety of health issues

The fourth annual National Rural Health Day is scheduled for Thursday. The yearly event is "an opportunity to 'Celebrate the Power of Rural' by honoring the selfless, community-minded, 'can do' spirit of that prevails in rural America," says the organization's website. "But it also gives us a chance to bring to light the unique healthcare challenges that rural citizens face–and showcase the efforts of rural healthcare providers, State Offices of Rural Health and other rural stakeholders to address those challenges."

"Today more than ever, rural communities must address accessibility issues, a lack of healthcare providers, the needs of an aging population suffering from a greater number of chronic conditions and larger percentages of un- and underinsured citizens," says National Rural Health Day. "And rural hospitals–which are often the economic foundation of their communities in addition to being the primary providers of care–struggle daily as declining reimbursement rates and disproportionate funding levels make it challenging to serve their residents."

National Rural Health Day consists of a series of webinars on: AgriSafe—Growing Families Strong: Protecting the People who Feed America, ORHP Quality Showcase, Rural Health 101: States & Communities at Work, ACA and You, Rural Policy and Advocacy Issues, and Collaborative Rural Success Stories. (Read more)

National Rural Health Day set Nov. 21 in Michigan; webinars available for those unable to attend

The third annual National Rural Health Day, which brings awareness to rural health issues and current efforts in addressing these issues, will be observed with events nationwide and special presentations in Sterling Heights, Mich., Nov. 21.

The National Organization of State Offices of Rural Health and all 50 state offices of rural health said in a news release that health concerns of the 60 million rural Americans include: a lack of health care providers; accessibility issues, particularly transportation and technology; and affordability, as the result of higher out-of-pocket costs and other factors.

"Meanwhile, rural hospitals and health systems face declining reimbursement rates and disproportionate funding levels that make it challenging to meet the physical, social and economic needs of their communities," organizers say.

The observance also focuses attention on state rural-health offices, which foster relationships, disseminate information and provide technical assistance that improves access to quality health care for rural citizens, according to the news release.

National Rural Health Day events include several free webinars. To learn more about the observance, visit http://celebratepowerofrural.org. Contacts: Bill Hessert at 814-360-1964, billh@nosorh.org; Teryl Eisinger at 586-850-5257, teryle@nosorh.org.