Transformation is on the horizon: Looking back on 35 years of rural health policy research

By Keith Mueller

Published on September 5, 2023

Portrait of Keith Mueller of the Department of Health Management and Policy at the University of Iowa College of Public Health
Keith Mueller

As I reflect on 35 years of research focused on rural health policy (my first few career years, ironically, focused on urban politics), I have stayed true to my “north star” – policy-relevant research and policy engagement to make a difference on behalf of rural people and places. My career blends health services research with policy engagement (at times advocacy), an ideal intersection for a political scientist.

Vulnerable populations are a special concern, beginning with my first federally-funded research (from what is now the Agency for Healthcare Research and Quality) estimating the percent uninsured at the county level in Nebraska using oversampling in 15 counties and then a bootstrap methodology to estimate rates in other counties, including counties with fewer than six persons per square mile. We used life-history calendars to understand lengths and consequences of uninsurance spells. My second funded research project focused on rural minority populations, funded by CDC/National Center for Health Statistics. My interest in vulnerable populations has continued, and is now a major theme in any federally-funded research, including what we do in the RUPRI Center for Rural Health Policy Analysis. 

The work related to uninsurance led directly to what is my passion, policies to reform how we finance and deliver services to assure access to high quality care for rural residents, in jargon of our field, health reform. Since joining the RUPRI Health Panel in 1993 I have been actively involved in federal and state policy-making. My federal policy-related research and analysis traces through major initiatives: the Health Security Act (HSA) in 1993-4 (first comprehensive health reform fill that actually reached the full Senate), the Balanced Budget Act (BBBA), 1997 (included major changes to the Medicare program), the Prescription Drug and Medicare Modernization Act (MMA), 2003, and the Patient Protection and Affordable Care Act (ACA), 2010. RUPRI’s research and analysis contributed to specific provisions:

  • analysis of rural implications of the HSA that informed subsequent incremental change;
  • simulation work that helped set initial payment parameters (including a rural floor payment) for what are now Medicare Advantage (MA) plans as part of the BBA, and analysis of the Medicare Rural Hospital Flexibility program in that statute;
  • empirical assessment of the impact of using multi-state areas and population-based standards to determine network adequacy for access to pharmacy services in the MMA;
  • and analysis of the rural impacts of provisions of the ACA, both during development of the bill and within 90 days after it was enacted.

Throughout those illustrations of policy development, published research established the credibility of RURPI researchers and analysts (e.g., our early work on the uninsured, studies of health system changes in rural places, policy analysis of health reform proposals, impacts of the MMA on rural pharmacies, and ongoing assessment of MA plan offering and enrollment). Perhaps more importantly, the RUPRI Health Panel and the RUPRI Center for Rural Health Policy Analysis have published highly respected and widely used policy documents (papers and briefs) that render our research and analysis immediately useful to practitioners and policy-makers. The final step, and the one I enjoy the most, is in-person interactions with policy staff and members of Congress to help in policy formulation and assessment. My 30+ years with RUPRI have provided multiple opportunities to conduct policy briefings for staff and others on Capitol Hill, interact directly with senior committee staff, and testify before Congressional committees, special commissions, and task forces (e.g., the Medicare Payment Advisory Commission and various special bipartisan commissions). High quality research and analysis has led directly to being engaged in the policy process.

Incremental policy development during the last 35 years has tended to address challenges in health care finance and delivery as discrete problems to address separately. However, leading into the formulation of the ACA, seeds planted by the HSA blossomed into a new approach of addressing three goals at once – improving access to services, restraining and reducing costs, and improving quality. My own work, and that of the various RUPRI branches (the Health Panel, the research center, and our technical assistance branch, Rural Health Value). We have built credibility as a source of research, analysis, and policy advice about how to transition our system to one that provides high value to rural people and places through payment and system reform sensitive to the special circumstances of sustaining essential services in rural places.

In our research portfolio we will continue studying the evolution of accountable care organizations in rural places, availability of essential services such as pharmacy and skilled nursing, impacts of different payment models on rural healthcare organizations, and health insurance coverage in rural places (including Medicare Advantage). I am especially interested in the intersection of public policy and strategic decisions made by healthcare organizations serving rural communities, which includes decisions made by large regional and national systems. I am excited about the future in health policy because the momentum to transform our system from one focused on volume of clinical services to one focused on the value provided to people and communities is, I believe, unstoppable. That means all that we believe in and advocate for in public health is possible, perhaps even on a near-term horizon. I want to contribute to that transition.