AMHERST — Last year’s federal reconciliation bill, H.R.1, gave sparingly and took dramatically from America’s healthcare safety net.
Beginning Jan. 1, new work requirements stipulate that adults between the ages of 19 and 64 qualify for Medicaid Expansion only if they’re working, studying, volunteering or participating in job training for at least 80 hours a month, with some exemptions. Once insured, recipients will have their Medicaid eligibility recertified every six months.
The Congressional Budget Office estimates changes included in H.R.1 will reduce federal Medicaid spending by $911 billion over the next 10 years. As a result, 10 million more Americans will be uninsured by 2034.
Just over half, 5.3 million, will lose their coverage as a direct consequence of Medicaid work requirements.
“Imagine going to renew your driver’s license every six months, going to the Registry of Motor Vehicles. How complicated, how difficult is that every six months?” said Tania Barber, president and CEO of Caring Health Center in Springfield. “If patients are going to lose their health insurance, that means patients are not going to come to get the healthcare that they need.”
Federal policy changes cast a long shadow over the Massachusetts Healthcare Summit at the University of Massachusetts Amherst on Tuesday, where state leaders discussed strengthening healthcare in rural and medically underserved communities, lofty goals made, conversely, more viable by a program established in the same sweeping piece of legislation.
Earlier this year, Massachusetts secured $162 million to expand access and strengthen healthcare infrastructure in the state’s non-metropolitan areas through the Rural Health Transformation Program, which was created in H.R.1, better known as President Donald Trump’s One Big Beautiful Bill.
These funds, the first apportionment of a five-year program running through 2030, won’t be “the white knight” offsetting existing or impending challenges, said state official Eliza Lake. The state cannot pay for transportation, housing or anything billable with these funds. But it can bolster rural health infrastructure and promote healthcare parity between eastern and western Massachusetts, doling out grants for technical assistance and capital investments in underinvested areas.
“What will be really transformative is if we can create a rural healthcare ecosystem and structure that is equal to the rest of the state — that equity would be transformative. And that it is sustainable, that was really our goal in writing the application and now in the implementation of the program,” said Lake, director of health policy and strategic initiatives at the Executive Office of Health and Human Services.
Community health centers
Community health centers form the backbone of local healthcare, as they’re required by federal law to provide care regardless of a patient’s insurance status or ability to pay.
Treating underinsured and uninsured patients can hamper these facilities’ financial vitality, their bottom lines becoming only further destabilized by changes to Medicaid. Approximately 61% of patients at Caring Health Centers receive Medicaid — 13,223 of the 22,000 individuals the centers serve. In all, they speak more than 50 different languages, Barber said, and the complexity of navigating changes in federal policy creates additional administrative burdens on staff.
“It also places the burden on the switchboard operators because they’re going to have to handle all of the incoming calls, our receptionists because they’re going to have to answer questions when people walk in the door. We are severely short-staffed,” Barber said.
Compounding patients’ apprehension about receiving medical care is another federal-level change in how U.S. Citizenship and Immigration Services (USCIS) officers evaluate applications for permanent residence: To determine whether a candidate for a Green Card might one day become a “public charge” dependent on social services, officers may consider whether the applicant’s family members currently access means-tested benefits, like Medicaid and food stamps.
Barber said that, in Springfield, some patients are terminating their care, or even their children’s care, to avoid jeopardizing active immigration proceedings.
“This is creating a chilling effect for the patients who need the care the most or need those services the most,” said Mary Ellen McIntyre, executive vice president of grants, programs and operations at the Massachusetts League of Community Health Centers. “This process is creating fear and confusion circulating in our communities, which is then causing families to avoid essential healthcare services or healthcare benefits that they need.”
Workforce development
Other persistent challenges facing the healthcare system, like the national nursing shortage, deepen along geographic boundaries.
Jay Prosser, executive director of the Nursing Council for Workforce Sustainability, said the field is hemorrhaging professionals as nurses report stress and burnout, unmanageable workloads and understaffed workplaces. Rural areas are especially vulnerable: The Health Resources & Services Administration projects that, by 2028, nonmetropolitan areas will have a 24% shortage of registered nurses, compared to a 5% shortage in metropolitan areas.
“Nurses are in high demand, but they leave in droves. You can earn a six-figure salary, nurses, but they’re leaving because of workload, violence, things like that,” Prosser said. “We talk about the nursing supply line, how we get more nurses in the workforce, but unless we plug the hole, we are in a pretty bad situation.”
To counter the exacerbating effect of nursing schools consolidating — including at Anna Maria College, which transitioned its nursing program to Assumption University in Worcester — Prosser suggested incentives for nursing students and investments in nursing education in rural areas, where nurses can remain rooted long after they complete their training.
Instead of requiring nurses to complete clinical hours without pay, for instance, nurses-in-training could be compensated for their work as clinical faculty, he said.
“These nurses, if you grow your own, you can be very, very successful, and we can have nurses that actually stay in rural areas,” Prosser said.
Other uniquely rural challenges
Competitive salaries can be an especially important inducement in attracting healthcare workers to rural or economically depressed areas, where misconceptions about cost of living can lead hospitals to inadequately compensate their employees, said Allison van der Velden, CEO of Franklin County Community Health Center.
“There’s a sort of assumption that the cost of living is lower in rural areas, and so the wages can be lower. What we have found is that, especially for providers, meaning doctors, nurses, dentists, psychiatrists, anybody with that level of professional training, we actually need to be competitive with the urban area, meaning we need to pay enough that people will move to our region,” van der Velden said.
Housing and transportation constraints in these areas present another challenge. Patients in Franklin County and the North Quabbin region routinely rely on emergency services for care, even for health concerns as minor as flu-like symptoms, according to van der Velden.
“A lot of folks are accessing healthcare via 9-1-1. That is their healthcare. They’re not going to urgent care even. They’re just if they’ve got a problem, it’s 9-1-1,” she said. Public education about the appropriate avenues for seeking treatment can help reduce patients’ health-related expenses, and partnerships with EMS can ensure that a wider spectrum of treatment options reach patients when they do call 9-1-1.
These realities make it all the more essential, according to Adam Delmolino, a vice president at the Massachusetts Health and Hospital Association, to reinvest in telehealth and home care so patients don’t need to leave their homes to receive care.
Investment in telehealth, Delmolino said, has diminished since the pandemic, but in rural areas, where the nearest care facility may be difficult to access, especially for aging patients or those with mobility issues, telehealth can still be a vital care tool.
“We have to look at, by 2031, to look at care in the home, care that’s technology-based, we want it to be the default for where people should be seeking their care, because we know people do better when they’re in their own homes,” said Delmolino. “We’re still going to need facilities, we’re still going to need nursing homes, we’re still going to need in-patient hospital care, but we can rely upon it less as we’re going down this road.”
