Last year, Republicans in Congress cut Medicaid outlays and refused to extend Affordable Care Act enhanced subsidies. Yet less federal spending on health care threatened to affect a key Republican constituency: rural voters. To avoid retaliation for their actions, Republicans included $50 billion for rural health care in the One Big Beautiful Bill Act, to be spent in various ways.
Here is the bad news. Even before last year’s legislative actions, rural areas in the U.S. were losing doctors, hospitals and even pharmacies. That trend is likely to continue, and neither party has a realistic plan to deal with it.
There is good news, however. More than 96 percent of Americans live within 90 minutes of a full-service hospital. That is the time span within which a procedure can be used to open a blocked coronary artery during a heart attack, avoiding death and disability. In contrast, only 71 percent of Canadians live within that window.
Also, specialists at the Mayo Clinic are treating thousands of stroke victims in rural settings every year across several states via telemedicine, usually within minutes of their arriving at the emergency rooms. Drones can deliver blood, vaccines and emergency medicines to rural hospitals, including clot-busting drugs for strokes, antivenom for snake bites and antibiotics for trauma. In fact, drones are already doing this on a regular basis in many African countries.
Nurses practicing at the top of their training can provide many of the services that are not being provided by medical doctors. And alternative payment methods, such as a monthly fee for all primary care, are replacing fee-for-service medicine with 10,000 billing codes that impose huge administrative costs on small medical practices.
In order to take full advantage of telemedicine, drones, alternative medical personnel and different payment systems, we need changes in dozens of state and federal laws.
Take telemedicine. In general, a doctor in one state can’t care for patients in another state unless that doctor is licensed in both states. For Mayo Clinic doctors to treat stroke victims in all 50 states, that means the doctors need to be licensed to practice in all 50 states. During COVID, most states suspended their restrictions on telehealth across state lines, but most of them have since been reimposed. Where you find exceptions, there are usually legal hurdles that are costly and burdensome to surmount.
In an ideal world, doctors licensed to practice in any one state would be free to practice in any other state via telehealth.
Drone technology could also be a lifesaver for patients in rural communities. One would think that in a large rural state like Texas, drone delivery of drugs, blood and medical supplies would be commonplace. But it is not. To have a drone delivery system for rural Texas, medical centers must confront a host of federal aviation regulations, on top of Texas’s own regulations. Cities can pile on their own laws as well.
Compared to the robust programs underway in such countries as Rwanda, Ghana, Nigeria and Kenya, Texas and other U.S. states are living in the technological Dark Ages.
Liberating potential providers of care is another pathway we should follow. Right now, only 27 states and Washington D.C. allow nurse practitioners to independently practice to the full extent of their training. Texas is one of 11 states that do not allow nurses to do much of anything without a doctor’s supervision.
If doctors want to live in big cities, Texas nurses who want to practice at the top of their training also have to locate in big cities so they can be “supervised.” The cost of such supervision can be payments to doctors totaling thousands of dollars a year.
Finally, we must rethink payment systems. What used to be called “concierge care” for the wealthy now goes by the term “direct primary care” when it is made affordable for most families. Atlas MD in Wichita, Kansas, for example, charges $50 a month for adults ages 20-44 and $10 for a child in return for all primary care, along with “unlimited access” to doctors. This type of 24/7 care avoids the administrative cost of thousands of billing codes and allows doctors to practice medicine the way they were taught in medical school.
An important feature of the One Big Beautiful Bill Act now allows Health Savings Accounts to be used to pay the monthly fee of direct primary care doctors. Employers can make deposits to those accounts, and employees can contract with a direct primary care doctor of their choice.
We also need to allow Health Savings Accounts and access to direct primary care for enrollees in Medicare and Medicaid. This would give rural patients options for primary care, both on site and via telehealth.
