Premiums for health plans offered through insurance marketplaces are expected to increase substantially in the coming year, but a new report co-authored by a University of Iowa health policy researcher shows that rural areas of the United States already face higher premiums compared to urban places, and the gap appears to be widening.
Keith Mueller, professor and head of health management and policy at the University of Iowa College of Public Health, joined colleagues from the Brown School at Washington University in St. Louis in a study of data on 2016 premiums from the Centers for Medicare & Medicaid Services, as well as information compiled from state-based marketplaces. They found that premiums had increased disproportionately in rural areas. The data differed from previous years, when urban and rural premium increases did not show a consistent pattern.
The researchers cautioned that their study focused only on premiums without accounting for subsidies and other cost-sharing adjustments that reduce the actual cost of insurance coverage for the majority of consumers.
The researchers found average adjusted premiums in rural counties are higher than in urban counties, with a widening gap in 2016 for both federally operated marketplaces and state-based marketplaces. In 2016, rural averages in the federally operated marketplaces were $306, compared to urban averages of $287. In the state-based marketplaces, rural averages were $285, compared to urban averages of $245.
Health insurance marketplaces, also known as exchanges, were established under the federal Affordable Care Act (ACA) as a resource for individuals, families, and small businesses to access, compare, and purchase health insurance plans. The exchanges are intended to restrain premium increases by encouraging competition among health plans.
The researchers also observed a disparity between rural and urban areas in terms of the number of insurance companies participating in exchanges. In 2016, urban counties had an average of 4.2 firms participating, while rural counties had an average of 3.2 firms participating.
“If premiums are higher in areas with less competition among firms, and less competition is occurring in rural areas, then there is a differential in premiums that is affecting people based upon where they live,” the researchers noted.
The report was conducted by the RUPRI Center for Rural Health Policy Analysis, based in the University of Iowa College of Public Health. This study was supported by the Federal Office of Rural Health Policy in the Health Resources and Services Administration, under the U.S. Department of Health and Human Services. The full report is available on the RUPRI website.
Under a contract with the Iowa Department of Public Health (IDPH), researchers from the UI Center for Health Policy and Research evaluated 13 health workforce development programs overseen by the state’s Bureau of Oral and Health Delivery Systems. The programs are integral to IDPH’s activities to secure high quality health care coverage throughout Iowa.
Led by Keith Mueller, Gerhard Hartman Professor and head of health management and policy, the team studied the programs’ scope and impact, and identified gaps and impediments to success. Eight of the 13 programs currently receive annual state-appropriated funds totaling $2,668,000. As part of the program evaluation, recommendations for fund-allotment to improve outcomes were made.
“We recommend that the state continue to target specific needs such as mental and dental health and fund approaches that promote recruitment and retention, including providing expanded training,” said Mueller. “IDPH administrators will continue to monitor program performance and shape future directions for developing Iowa’s health workforce, including appropriate reallocation of resources among existing programs. These programs represent the state’s response to needs of Iowans for proximate access to vital services, and ongoing evaluation will be important.”
This project was funded by IDPH and the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. The executive summary and the full report are available online:
A new research report by the Rural Policy Research Institute’s Health Panel, which includes University of Iowa faculty and is supported by research staff in the UI Department of Health Management and Policy, outlines the challenges and opportunities confronting rural providers, policymakers, and health systems as they work to implement reforms in rapidly expanding state Medicaid programs.
The report notes that efforts to reform the health care delivery system are gaining momentum among all payers and within Medicaid programs in particular, given their significance to a growing population as well as to state budgets. The report calls on policymakers to “recognize both the desirability and shortcomings of new delivery system models for rural patients and providers.”
“While both national and state policymakers shape Medicaid reform, state-level policies have the potential to encourage a broader statewide focus on population health by connecting Medicaid to other important and impactful state-level resources, like human and social support services and public health,” the report states. “In implementing policies that promote delivery system reform, it is important to consider how certain models may be capable of either promoting access for rural populations or diminishing it.”
According to the report, broadened eligibility under the federal Affordable Care Act (ACA) nearly doubled the percentage of people covered by Medicaid programs — from 10.4 percent of the U.S. population in 2000 to 19.5 percent in 2014. As of January 2016, more than 72 million people nationwide were enrolled in Medicaid.
The significance of state Medicaid programs is even greater in rural areas where, as of 2014, 22 percent of residents were enrolled. Medicaid has surpassed Medicare as the largest source of public health coverage in rural areas, and is second in coverage only to employer-sponsored insurance plans. The program is also a crucial source of provider payments in rural communities.
The report identifies six recommendations for rural policymakers, providers, and communities. The recommendations are:
- Promote integrated and comprehensive primary care delivery.
- Promote integrated and comprehensive care across the health care continuum.
- Promote accountability for the health of the Medicaid population in rural communities.
- Promote measures, reporting standards, and payment approaches relevant to rural providers.
- Promote payment designs that recognize the nature and circumstances of rural providers and systems.
- Provide technical assistance to rural providers during the Medicaid transition to value-based payment.
The report was authored by the RUPRI Health Panel, which is chaired by Dr. Keith Mueller, professor and head of health management and policy at the University of Iowa College of Public Health. The work was supported by the Leona M. and Harry B. Helmsley Charitable Trust. The full report is available at the RUPRI website.
Keith Mueller, Gerhard Hartman Professor and head of the Department of Health Management and Policy, was chosen by the selection committee of the Faculty Senate as one of six members of the University of Iowa faculty to receive a 2016 Regents Award for Faculty Excellence.
The award is one of Iowa’s highest honors for faculty achievement. Mueller’s selection is a testament not only to his outstanding accomplishments in teaching, scholarship, professional commitment and service to the university, but also to his colleagues’ high regard for his contributions to our academic community.
Mueller is the director of the Rural Policy Research Institute (RUPRI) Center for Rural Health Policy Analysis. He has worked diligently to place the research of the RUPRI Center on the national scope of health policy. He has excelled in scholarly productivity by increasing funding for RUPRI, which in turn has created additional research opportunities for faculty, staff, and students.
Since joining the College of Public Health in 2010, Mueller has increased his activity in service to rural communities. He serves on the Board of the Iowa Rural Health Association and was their 2015 president. He also served as president of the National Rural Health Association and is a member of the National Advisory Committee on Rural Health and Human Services.
On Monday, March 7, the College of Public Health was pleased to host a meeting of the advisory committee for the Iowa Department of Public Health’s Center for Rural Health and Primary Care. The centerpiece of the meeting were presentations on Rural Health Policy by Keith Mueller, professor and head of health management and policy, and Chuck Fluharty, clinical professor of health management and policy and CEO of the Rural Policy Research Institute (RUPRI).
“These presentations provided a global framing of rural issues and how to address emergent issues in rural health,” said Mueller. “The meeting was an excellent opportunity to showcase some of the unique rural policy expertise in the College of Public Health.”
Mueller’s presentation focused on major changes occurring in clinical and primary care, including rising rates of insurance coverage, new payment models that shift incentives from volume to value, and ongoing efforts to build high-performance health systems.
Fluharty’s presentation focused on rural innovation and opportunities for collective impact beyond the health sector. Fluharty discussed the need for regional policies that align rural and urban interests, while highlighting several RUPRI initiatives that are contributing to the development of thriving rural communities. One such initiative, a collaboration between RUPRI and Art of the Rural, engages artists, organizations, and communities in crafting strategies that foster rural economic and community development. More information can be found online at http://www.rupri.org/ .
UI College of Public Health 2015 Distinguished Faculty Lecture
Health Services Research Meets Policy and Practice to Benefit Rural People
Thursday, August 27
N110 College of Public Health Building
A reception will follow in the CPHB atrium.
Over the past 30 years, health services researchers have helped shape policy to strengthen health care delivery systems in rural America. Today, with the implementation of the Affordable Care Act, the U.S. faces transformational changes in health care organization, delivery, and finance.
To help rural people, providers, and places with this transformation, health services researchers and analysts must know as much as possible about those changes, how organizations can use the changes as opportunities, and what to expect as organizations adapt. In this presentation, Keith Mueller will discuss the tools, resources, and knowledge that researchers and analysts have to help make this transformation positive for rural and underserved populations.
Individuals with disabilities are encouraged to attend all University of Iowa-sponsored events. If you are a person with a disability who requires a reasonable accommodation in order to participate in this program, please contact the College of Public Health in advance at 319-384-1500.