Expanding Healthcare for Rural Residents in Maryland

Expanding Healthcare for Rural Communities Introduction Every American should have access to quality and affordable healthcare service, regardless of their socio-economic background. Ideally, individuals should be able to access services conveniently and confidently such as the following: primary care, dental care, behavioral health, emergency care, and public health services. These types of services should be accessed and are critical to good health. Unfortunately, those in rural areas and communities in the state of Maryland face unique health care concerns that include the lack of health care provider and difficulty access those providers due to transportation and technology barriers. In recent debate on the SB 707, state policymakers, legislators, and community represented highlighted these challenges that residents in rural communities’ face in accessing the healthcare system. Followed in some rural jurisdiction the loss of its only hospital eliminates the hub for health care in those communities’. Representatives from those communities have reminded state policymaker and legislator that in some rural communities that hospital and health care provider in these communities, are quite frequently the economic backbones. Thus, they continue to provide high-quality service and meet the need of rural residents 1 . To address these barriers that impede services and access within rural communities, as a candidate for the Maryland General Assembly representing Baltimore’s 40 th District, my policy recommendation offers several initiatives. In which are underway to address this issue directly, to provide affordable and accessible health care services in Maryland. My proposal includes three- policy recommendation targeting public insurance, private insurance, and the delivery system for residents in Maryland. The three-policy proposal includes the expansion of the following: state based universal health care; employer sponsored insurance, and mobile hospital clinic/ community healthcare workers. Public Insurance Identify Issue Although it is no secret that the American Health Care System is broken, there are other industrialized nations that have achieved universal coverage. In the United States we have millions that are underinsured or uninsured and can’t afford the care they need. We’ve prioritized profits over people for way too long. Following the expansion of Medicaid in Maryland this caused a drastic impact, in which there is a decrease in the rate of the uninsured, there are still major gaps in health care access. About 6% of Marylander are still uninsured, and Marylanders are living in or near poverty are almost three times likely to be uninsured 2 . This has particularly impact rural resident in Maryland. Background 1 Transforming Maryland’s rural healthcare system: A regional approach to rural healthcare delivery. (n.d.). Report of the Workgroup on Rural Health Delivery to the Maryland Health Care Commission , 3–20. https://doi.org/https://mhcc.maryland.gov/mhcc/pages/home/workgroups/documents/rural_health/Final %20Report/LGSRPT_FinalReport_rpt_23102017.pdf 2 Schablein, J. (2022, March 17). Opinion: Maryland needs the Commission on universal health care . Maryland Matters. Retrieved December 5, 2022, from https://www.marylandmatters.org/2022/03/17/opinion-maryland-needs-the-commission-on-universal-health-care/

Universal Healthcare is a healthcare system where every citizen of a specific region or nation can access affordable and efficient healthcare services. Universal Healthcare centers on the 1948 World Health Organization's constitution, which notes that health is a vital human right. Universal Health Coverage features almost all Sustainable Development Goals (SDGs) that relate to health; it gives hope for quality healthcare services, especially for the underprivileged. Originally, in 1948 the newly elected President Harry Truman set out to establish national health insurance in the United States. In which, he had gained the support from the American public. The National Health Insurance was seen as a threat by the American Medical Association (AMA), which quickly launched a $1.5 million counter-campaign, which is about $16 million in today’s dollars, thus indicating that the plan would result in low quality medical care 3 . Those that opposed the NHI efforts was due to believing physicians would lose their autonomy, being required to work in a group practice model and be paid by salary or capitated methods. In addition, to business, labor groups, and emerging private health insurance industry were not supportive 4 . A decade after President Trumans failed attempts to established national health insurance, Bill Clinton ran for election with universal health care as the main point of his platform. Despite winning the election, President Clinton was never able to pass his health care reform legislation. One of the reasons for this failure was the opposition of interest groups, such as the AMA. These interest groups have thwarted many policies as demonstrated in the campaign against Truman. This would be done through indirect means, such as campaign influencing public opinions, and sometimes it would be as overt in collaboration with individuals’ politicians 3 . Following in 2021 the closest the nation has come to a universal health care is the Affordable Care Act (ACA), also known as the Obamacare. Though there are a few flaws within the ACA there has yet to be attempts to successfully reform. Given the fight for universal health care has been raging for decades, most interest groups have asserted themselves in the conversation 3 . Political Feasibility/ Distribution Analysis Although the Commission on Universal Health Care has been proposed at the Maryland General Assembly, there have been opposition against the implementation of the SB493/HB610 Commission on Universal Health Care. There are many critics and arguments that the implementation of universal healthcare would not be feasible, organizationally, or financially, as compared to other developed countries. Given the potential of this recommendation, there are ideological difference regarding this implementation of a universal healthcare in Maryland. With the expansion of a state universal health care system, there will be likely winners and losers that will be impacted as a result. Firstly, the likely winners that the policy recommendation will impact are big employers and large insurance companies. In which the system would allow a managed competition between the two. In addition, this approach would work logically for most moderate Democrat who would want to both cut the deficit and free source for any new public interest. 3 Funk, C. (2021, April 2). Interest groups could be why America doesn't have Universal Health Care . Columbia Missourian. Retrieved December 5, 2022, from https://www.columbiamissourian.com/opinion/guest_commentaries/interest-groups-could-be-why-america-doesnt-have- universal-health-care/article_211efaee-8db6-11eb-bcc2-1762746cd974.html 4 National Health Insurance —a Brief History of reform efforts in the U.S. Kaiser Family Foundation . (2009, March). Retrieved December 6, 2022, from https://www.kff.org/wp-content/uploads/2013/01/7871.pdf

and setting the political objectives for medical and health care Swedish policy requires each regional council to offer citizens efficient medical care and a high-quality working environment to enhance better health for the general population. The municipalities care for the elderly in their home, while regional councils take care of the dental cost for citizens up to the age of twenty-three 8 . Although universal healthcare has many beneficial factors as demonstrated by the following countries there a few pitfall with the implementation. Given the benefits that universal healthcare has in those countries demonstrates the possible outcome for the state of Maryland, Therefore, The SB493/HB610 Commission on Universal Health Care should be possible solution. Constraint/Structural Barriers Cost: As mentioned the realization of a universal healthcare system in the state would necessitate significant upfront cost. Most of this cost relates to physical and technological infrastructure changes to the healthcare system. Acceptability : Accordingly, the implementation of a government-controlled health care is not acceptable to interest groups like the AMA involved. Currently, there are those that are opposing the implementation of the Commission on Universal Health Care, being that not only will states be paying for healthcare, but they will be in complete control and operation of the hospitals and employment of healthcare and medical staffs. Administrative Feasibility: Based on the information provided, the administrative constraints would center on securing a technical workforce to manage this system. Political Feasibility: Although this proposal is currently being sponsored in the Maryland General Assembly, there are many that have opposed to this so called “one-size-fits-all” approach as they labeled. Furthermore, this implementation would create tension between major political parties and interest group due to concerns of a “socialized medicine.” Although, this major shift could potentially take single-payer systems one step further. Policy Alternative Policy Alternatives related the expansion of Universal health Care, include a positive and negative impact of the goals of the policy. The first alternative would be to keep the single-player system currently in place in Maryland. Accordingly, to recent polls, this model has majority support from physicians. In addition, many numbers of states are continuing to pursue a single- payers’ options, after the demise of Vermont’s single-payer plan. Followed with others such as Massachusetts adopting a bill to study single-payers and implement a reform if the model is found to be less costly than alternatives 9 . Secondly, as recommended, the administration of universal healthcare would be ideally and politically feasible for Maryland. Given that the administration of this model has been successfully implemented in Canada, Denmark, and Sweden. Following this integration would help make medical cost more affordable and easier to access health service for rural resident in the State of Maryland. Conclusion 8 Impact report . Impact Report | Mobile Health Map. (n.d.). Retrieved December 4, 2022, from https://www.mobilehealthmap.org/impact- report 9 Fox, A., & Poirier, R. (2018). How Single payer Stacks Up: Evaluating Different Models of Universal Health Coverage on Cost, Access, and Quality. International journal of health services: planning, administration, evaluation , 48 (3), 568–585. https://doi.org/10.1177/0020731418779377

Based on the analysis and information provided the likelihood of integrating a Universal Healthcare model in Maryland would not be acceptable, given that many interest groups and medical practitioners fear the loss of their autonomy. Private Insurance Identify issue The health coverage varies in between rural and urban America, but also among rural residents. Accordingly, to studies, rural residents are more likely to be uninsured than urban residents. This coverage difference is due to a more limited access for rural workers to employer- sponsored health insurance. In addition to lower wages, and the tendency for rural residents to work for smaller employers, have accounted for this reduced access 10 . The non-elderly population in rural area is more likely than metropolitan counterparts to live in a family without either a full-or part-time worker (17% versus 14%). Furthermore, among workers, those rural residents are more likely to work in blue collar jobs (jobs outside of managerial, business, and financial occupations) than workers in metropolitan areas (71% versus 63%). Blue-collar workers earn less and have fewer overall benefits than white-collar workers. Half of all rural workers work in “Low ESI industries,” or industries in which less than 80% of workers are covered by employer-sponsored insurance coverage 11 . Background Long before the passage of the federal health care reform act in 2010 which eventually imposed an individual mandate to obtain health insurance, policy makers had considered the alternative approach of employer health insurance mandates as a strategy for expanding coverage. At the Federal level, the failed health care reform plans proposed by the Nixon administration in the early 1970s and the Clinton administration twenty years later both included an employer mandate. At the state level, laws imposing employer mandates in Massachusetts (1988), Oregon (1989), Washington (1993), and California (2003) were overturned by voter referendums or voided due to conflicts with the federal Employee Retirement Insurance Security Act (ERISA). Since these laws have not been adopted, direct evidence regarding the effects of an employer sponsored insurance (ESI) mandate is scarce 12 . Following the impacts of the ACA, coverage gains have resulted in a drop in the uninsured rate for Marylanders between the ages of 18 and 64, from 11.3% in 2013 to 4.0% in 2016. The largest reductions in the uninsured rate have been observed among the Hispanic and African American populations, declining from 18.0% to 7.0% and 16.0% to 6.0%, respectively. In addition, individuals between the ages of 18 and 34 have experienced a decrease in the uninsured rate from 15.0% to 4.0%, the largest drop among age groups. Counties on the Eastern Shore and in the western regions of the State have some of the highest rates of ACA enrollment in the State, benefitting from the Medicaid expansion. An analysis by the State Health Access Data Assistance Center indicates that the areas of the State with the highest percentage of individuals (more than 68.0%) who are eligible for marketplace coverage but have not enrolled 10 Anderson,, N. J., Ziller , E. C., Race , M. M., & Coburn, A. F. (n.d.). Impact of employment transitions on health insurance coverage of rural ... Retrieved December 5, 2022, from https://muskie.usm.maine.edu/Publications/rural/WP46/employment-transitions-rural-health- insurance.pdf 11 Newkirk and Anthony Damico Published: May 29, V., & Damico, A. (2014, May 29). The Affordable Care Act and insurance coverage in rural areas . KFF. Retrieved December 4, 2022, from https://www.kff.org/uninsured/issue-brief/the-affordable-care-act-and-insurance-coverage-in- rural-areas/

Hawaii’s experience suggest that requiring employers to offer insurance can significantly increase coverage 13 . Given the significant impact of ESI from Hawaii, there are strength and weakness within this system. As indicated in the Massachusetts law, the state imposed a ‘‘pay or play’’ requirement on employers, in which those that do not provide health benefits must pay a ‘‘fair share’’ contribution toward the cost of their employees’ insurance 14 . Following the employer mandate proposal would include exemptions for small firms or firms employing a large proportion of low-wage workers. The benefit of these type of exemptions recognizes that unemployment may be an unintended consequence of an employer mandate should employers of such firms be unable to fully absorb the cost of the mandate or pass the cost onto low-wage workers in the form of reductions in wages or other benefits 13 . Constraint/Structural Barriers Cost: The cost associated with an employee sponsored mandate for small business in rural areas would include the effects of comprehensive provider payment and the overall sustainability of the program. Acceptability: Based on analysis, the mandate of ESI would not be widely accepted, being that its puts cost pressure on employee contributions. In addition to altering the nature of employment relationship in the U.S would cause some observers to pause, regarding the ability of ESI to remain a reliable source of coverage. Administrative Feasibility: Admirative cost associated with ESI would be securing a technical workforce, given that ESI requires the creation of new information technology. Political Feasibility: Following this implementation under the ACA, the expansion of an employer sponsored mandate in Maryland would be moderately low. Although Maryland is friendly towards small business it may be opposed by insurance companies covering small rural areas. Given those with opposition would argue that compelling individuals to obtain coverage, will be forced to purchase a different of goods, making this option worse off. Policy Alternative In following the implementation of this recommendation there are policy alternative that are related to this expansion of ESI. Given that the current policy proposal would not feasibly be supported by small business to expand insurance for rural residents. This would most likely weaken this so called “glue” holding the current employment-based system together and could potentially unravel the insurance market. A huge risk that Maryland is unlikely to take. Secondly, the new bill that Maryland currently introduced at the Maryland General Assembly, is the SB632. The bill would provide up to $45 million in subsidies each for Maryland’s small business and nonprofits to provide employees with health insurance. Conclusion Based on the information and analysis provide the effects of the ESI will depend on the level of enforcement by Maryland. Given the state is friendly toward small business, it would be unlikely the proposal would pass, given the mandate alone will not guarantee success. Delivery System Reform 14 Massachusetts Health Care Reform: Six Years Later. (2013). Retrieved from https://www.kff.org/wp-content/uploads/2013/01/8311.pdf.

Identify Issue Given the recognition of unstainable healthcare cost growth and suboptimal deliver system performance in the United States, the Patient Protection and Affordable Care Act of 2010 (ACA) contains provisions that redesign healthcare payment and delivery. Because of the change in ACA payment provision, this has driven delivery system reform by making healthcare organizations more accountable for patient’s health. However, efforts to date have been concentrated in urban centers, with little attention to how they might be applied in a rural health system. For those living in rural areas and communities, their hospital is an important, and often only source of health care. Due to the unique health care landscape and geographic landscape of most rural communities, there is a struggle with delivery service. In which many individuals are isolated from services and may be unable to access service to live safely and independently 15 . This policy goal will be achieved through the investment in mobile health clinics and expand rural involvement through the utilization of Community Health Workers (CHWs). Background Following the many investments and support in the health of it rural resident, Maryland commitments are reflected in the creation of key government and non-profit organization that provide leadership, investment and guidance to promote health and well-being for rural communities and their residents 1 . In Maryland, the state has a unique hospital payment model, which has been a key policy for softening the impact of declining hospital utilization on local hospital. In the past decade, the Health Services Cost Review Commission (HSCRC) has worked with rural hospitals to develop an alternative payment model, Total Patient Revenue (TPR) that was especially well-suited to the needs of rural hospitals. The success of that model was one factor that spurred Maryland to establish the All-Payer Model Demonstration Agreement (All Payer Model, or Agreement) with the Center for Medicare and Medicaid Services (CMS) in 2014 1 . The mobile health clinics (MHCs) provide an additional opportunity for states to lead in the expansion of rural health care access and delivery system. According to researchers at the American Journal of Managed Care, mobile clinics is defined as “customized vehicle that travel to the heart of communities, both urban and rural, and provide prevention and health care service where most people work, live, and play 16 .Currently, there are an estimated 2,000 mobile clinic located across country, representing all state and the Washington, D.C. The implementation of mobile clinics enables state to overcome barrier of time, money, and provides community- tailored care to those in rural areas and communities. Many of the service included: are primary care, preventative screening, disease management, behavioral health, dental care, pre-natal care, and pediatric care 17 . A community health worker (CMWs) is “a frontline public health worker who is a trusted member of and/ or have a close understanding of the community served 18 .” There are more than 120,000 community health workers on the job in neighborhood, homes, schools, work sites, 15 Bhatt, J., & Bathija, P. (2018). Ensuring Access to Quality Health Care in Vulnerable Communities. Academic medicine : journal of the Association of American Medical Colleges , 93 (9), 1271–1275. https://doi.org/10.1097/ACM.0000000000002254 16 Yu, S. W. Y., Hill, C., Ricks, M. L., Bennet, J., & Oriol, N. E. (2017). The scope and impact of mobile health clinics in the United States: a literature review. International journal for equity in health , 16 (1), 178. https://doi.org/10.1186/s12939-017-0671-2 17 Impact report . Impact Report | Mobile Health Map. (n.d.). Retrieved December 4, 2022, from https://www.mobilehealthmap.org/impact- report 18 Islam, N., Nadkarni, S. K., Zahn, D., Skillman, M., Kwon, S. C., & Trinh-Shevrin, C. (2015). Integrating community health workers within Patient Protection and Affordable Care Act implementation. Journal of public health management and practice: JPHMP , 21 (1), 42–50. https://doi.org/10.1097/PHH.0000000000000084

issues on a community wide level. According to economic studies mobile clinics can be cost- effective in providing annual savings of up to $36 for every $1 spent invested comparted to emergency room visits. Following impact reports captured through the Mobile Health Map have demonstrated the success of local mobile clinic. Although this program has varied by individual county needs, emergency medical services professional used for making health wellness visit with high utilizers to avoid hospitalization, stabilization services calls to prevent transport to hospitals. In addition to providing a crucial link between the physical health and mental health. It is through this type of clinics that will decrease hospital admission and readmission and helping people to get the services they need within their community, rather than traveling to the nearest hospitals 22 . According to recent studies, the clinic provides a variety of services with; 42 percent providing primary care services, and 30 percent offering dental service. As indicated these clinics are served to be effective at improving health outcomes, especially among population who would otherwise have no access to healthcare providers. An example is that mobile clinic patient in Baltimore were more than 6.5 times more likely to receive an HIV screening than patient receiving care from a traditional clinic in the city. In Louisiana, about 30 percent of high blood pressure patient saw a decrease of their blood pressure after receiving care at the mobile clinic. In addition, there is ample evidence, CHWs can improve outcome, produce cost savings, and reduce disparities 23 . In addition, Community health workers subsequently played a highly visible role by helping more than 200,000 uninsured people enroll in health insurance programs, as mandated by law. As a result, CHW strengthen community capacity to improve social determinant of health, including inadequate education and lack of access to health insurance 16 . Constraint/Structural Barrier: Cost: Despite the many opportunities and benefits, mobile clinics face a significant financial barrier to operate. They have overwhelmingly served uninsured patients and therefore have also relied on third-party funding source to cover the cost of providing care. However, sustaining CHW has been a challenged in the United States due to short-term program funding. The Affordable Cares Act recognizes CHW as important members of the healthcare force and, as of 2014, Medicaid can reimburse for CHW services, if recommended by a physician or other Medicaid-enrolled licensed practitioner. However, CHWs are often under-compensated for their contribution and has been a challenge to secure sustainable funding for CHW. This lack of awareness and guidance on legislation related to the reimbursement of CHW service may hinder organization’s ability to sustain CHW programs 24 . Acceptability: According to my analysis, the expansion of mobile clinic/CHWs in rural communities of Maryland would be widely accepted. It is through this implementation that potential options would be applicable and scalable to rural communities in Maryland. In addition, the options identified align with the Demonstration Agreement that Maryland signed with CMS in 2018. 22 2018 Maryland Rural Health Plan. (n.d.). Retrieved from https://health.maryland.gov/pophealth/Documents/Rural%20Health/MDRH-Plan- 2018.pdf. 23 Community Health Workers: Recommendations for Bridging Healthcare Gaps in Rural America. (n.d.). National Rural Health Association Policy Brief. 24 Mehra, R., Boyd, L. M., Lewis, J. B., & Cunningham, S. D. (2020). Considerations for Building Sustainable Community Health Worker Programs to Imp Maternal Health. Journal of primary care & community health , 11 , 2150132720953673. https://doi.org/10.1177/2150132720953673

Administrative Feasibility: A constraint regarding administration, would be the retaining and recruiting CHWs into the rural communities, in addition to securing workforce groups and participants capacity. Political Feasibility: Under the information provide, the expansion of mobile health clinic and CHWs would be widely accepted for rural communities. Given that Maryland has an established workgroups on rural health delivery, there are many supports from individuals representing the interests of healthcare providers, businesses, labor, State and local government, consumers, and other stakeholder groups. Conclusion The inclusion of mobile clinics and CWHs would most likely be successful at the Maryland General Assembly, given that Maryland has been very innovative with their delivery system and supporting the organization of workgroups to addressing rural communities.