Hill Supports Medicare Boost To Rural Areas

back

Want to support Global Action on Aging?

Click below:

Thanks!

Hill Supports Medicare Boost To Rural Areas

By Amy Goldstei, The Washington Post Staff Writer
October 20, 2003

Congress's drive to expand Medicare by helping older Americans pay for prescription drugs also calls for the largest boost in rural health care spending in the program's recent history: at least $25 billion more for doctors, hospitals and other medical services.

Despite long-standing claims that Medicare has shortchanged rural areas, however, there is scant evidence that elderly patients in remote areas and small towns have trouble getting adequate care, according to health care analysts, organizations and providers.

These sources have found that Medicare often pays comparatively low rates in rural states and that older patients are more common there. But there are few signs that rural residents -- who make up nearly one-fourth of the 40 million people on Medicare -- are sicker, less satisfied with their care or less prone to get the treatment they need.

"The evidence that there are access problems that can be solved by throwing tons of money in these areas is relatively scant," acknowledged one Senate Republican aide who has nevertheless been working to ensure that the Senate's version of the proposed spending hike -- slightly more generous than the House's -- ends up in the final Medicare legislation that House and Senate negotiators are trying to shape. On Friday, lawmakers who have been trying to resolve the two bills reported progress in several areas but few firm agreements.

Key lawmakers in both parties, along with President Bush, support higher rural payments by Medicare. The idea has caught on even as Congress is having difficulty finding the means to subsidize drug coverage to the level that many elderly people want.

The payments are an example of the many agendas woven into the Medicare legislation, the most significant domestic issue remaining before Congress this year. Lawmakers and White House officials say their main goals are to create drug coverage and a larger role for private health plans in the insurance programs for Americans 65 and older. But groups of people with specific diseases and segments of the health care industry also would benefit from the legislations' many other components.

The proposed "rural equity" provisions result from lengthy and intense lobbying -- as well as the influence of a few well-placed lawmakers. The chairman and ranking Democrat on the Senate Finance Committee, which handles Medicare, are Sens. Charles E. Grassley (R-Iowa) and Max Baucus (D-Mont.), respectively -- key participants in the House-Senate negotiations who come from states where comparatively low Medicare payment rates are a long-standing complaint.

The bills would promise $25 billion to $28 billion in the next decade. Perhaps $15 billion would go to rural hospitals, $5 billion to physicians and the rest to home health care companies and other providers of medical services in rural areas. Under the House version, that money would come at the expense of other parts of the Medicare system, because it is included in the $400 billion that Congress has set aside to improve the program.

With politicians in both chambers eager to reap credit, House members have boasted that their legislation would represent the largest single addition to Medicare payments for rural communities the chamber has ever approved. And they note that, under their bill, the extra help would start in 2004, a year before the Senate's.

The Senate's rural health champions, on the other hand, criticize the way the House would pay for that assistance: partly by giving hospitals throughout the country $12 billion less than Medicare otherwise would pay them in coming years. "The House gives with one hand and takes with the other," said another GOP Senate aide. A trade group recently began running a newspaper ad, decrying the House bill's proposal to generate money for the rural payments by charging new fees to Medicare patients who use home health care.

The Senate, instead, would try to reduce overpayments for drugs that Medicare pays when patients are hospitalized; freeze part of the program's subsidies for medical training; and add fees for lab tests.

Such distinctions between the bills, though, are nearly drowned out by the broad enthusiasm for increasing rural payments, even when Congress is struggling with escalating federal deficits and the White House's request for $87 billion to pay for the aftermath of the wars in Iraq and Afghanistan .

Companies and groups that would benefit from the higher rural payments are lobbying hard. Grassley's state of Iowa has been a hub of this effort. It is home to the Geographic Equity in Medicare Coalition, a group of physicians that has grown to include 25 state medical societies. Iowa 's hospital association has been vocal, too.

Leaders of these groups and other advocates say it is unfair that working Americans nationwide contribute the same amount in Medicare payroll taxes but that health care providers in urban areas tend to get higher government reimbursements for the elderly patients they treat. Iowa 's advocates often note that the state ranks last in the amount per patient that Medicare spends in that state.

But two former administrators of the agency that runs Medicare -- a Democrat and a Republican -- testified at a hearing Grassley convened in Iowa last spring that the statistic was meaningless because it ignored the fact that older Iowans are healthier than most Americans so they need less care and, when they get sick, sometimes go to hospitals across state lines.

Similarly, there is little substantiation for advocates' assertions that rural doctors are so underpaid that they are reluctant to accept new Medicare patients. In fact, the proportion of rural physicians taking new elderly patients remains high -- 97 percent -- and slightly exceeds that among city doctors, according to a survey last year for the Medicare Payment Advisory Commission (MEDPAC), which advises Congress on Medicare policy.

In the most detailed recent analysis of health care among rural and urban Medicare patients, MEDPAC concluded two years ago that there was relatively little difference in the percentage who got necessary care for nearly 50 medical problems -- or even in the percentage of patients who had to travel more than an hour to find care. MEDPAC has recommended increases in rural payment that are smaller than Congress envisions.

Officials at AARP, the largest advocacy group for older people, checked at The Washington Post's request with its affiliates in eight rural states and found that none had gotten significant numbers of complaints from members having trouble finding care.

"Maybe there is a political dynamic, as opposed to a true problem," said Paul B. Ginsburg, president of the Center for Studying Health System Change, which has sent the Senate its own findings that there is little difference in access to care between rural and city Medicare patients.

Other work, by Dartmouth researchers, has gone further, suggesting that Medicare patients actually are healthier in parts of the country -- many of them rural -- where the program's payments are low. Areas with high payments tend to have an excess of doctors, who give patients more tests and specialized services that do not truly improve health, the researchers found.

Such conclusions run counter to feelings on Capitol Hill. Last April, when the Senate first approved -- with 86 votes -- the package of rural health payments as part of a tax bill, senators from rural states "kept coming up and giving Grassley hugs," an aide recalled. Bush sent a letter to Grassley, reminding him that they had pledged to work together on "our concerns that rural Medicare providers need additional help."

The importance of this extra money to Grassley was particularly evident in late August, as the conference committee of House and Senate members was beginning the difficult negotiations that are still underway to meld the Medicare bills the two chambers had adopted in late June. Grassley, the Senate's lead negotiator, proposed to the conference's chairman, Ways and Means Committee Chairman Bill Thomas (R-Calif.), that they announce an agreement on the many aspects of the rural payment increases that are the same in both bills.

Thomas refused, apparently reluctant to risk yielding any negotiating leverage later by resolving early an issue of such importance to the Senate conferees. Grassley directed his staff to boycott the negotiations for a week. The matter still unresolved, the aides eventually returned, and the negotiators reached tentative agreements on some -- but not all -- of the rural payment questions early last month.

Rural health advocates dispute the findings that their patients get enough care, telling lawmakers that such communities have trouble recruiting doctors and other health professionals because the program doesn't pay them enough. "The only way we are going to be successful is to have equal pay for equal work," said Michael Kitchell, a neurologist at the McFarland Clinic in Ames , Iowa . He said that he and many colleagues spend several days a month driving to smaller clinics or hospitals in remote areas where doctors are scarce. "Those hours behind the windshield are not reimbursed by Medicare," Kitchell said.

Daniel Muniak, the physician's assistant for the past 16 years at Garfield County Health Center in east-central Montana , said that Medicare pays far less than the clinic charges patients for routine services such as X-rays and electrocardiograms. "We end up eating some of the bill," he said.

When pressed, some of the advocates say that Medicare payments are not their entire problem. Their finances, they say, also are weak because of their relatively large volume of low-income patients and recent state cuts in the Medicaid insurance program for the poor. And filling medical jobs is difficult partly because some doctors prefer to live in more cosmopolitan places.

"I'm a skeptic" about the need for Congress to increase payments, said Christopher Hogan, a private consultant in Northern Virginia who researches Medicare. "The problems of Medicare in rural America are primarily the problems of rural America , not the problems of Medicare."