RUPRI researchers examine Medicaid reform in rural settings

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:

  1. Promote integrated and comprehensive primary care delivery.
  2. Promote integrated and comprehensive care across the health care continuum.
  3. Promote accountability for the health of the Medicaid population in rural communities.
  4. Promote measures, reporting standards, and payment approaches relevant to rural providers.
  5. Promote payment designs that recognize the nature and circumstances of rural providers and systems.
  6. 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.

Fluharty honored for distinguished leadership in rural development

Charles Fluharty, clinical professor of health management and policy, and founder, president, and CEO of the Rural Policy Research Institute (RUPRI), was recently honored by Iowa Wesleyan University as the inaugural recipient of the Presidential Medal for Outstanding Merit.

Portrait of Chuck Fluharty
Charles Fluharty

The award, conferred during the Iowa Wesleyan University commencement ceremony on May 7, recognizes Fluharty for “lifelong and exemplary leadership and commitment to advancing the development of rural life and communities.” The award also acknowledges the extensive work of RUPRI over the past 26 years to address “the full range of policy and program dynamics affecting rural people and places.”

Fluharty’s career has focused on service to rural people, primarily within the public policy arena. A seasoned policy analyst and practitioner, he has authored numerous policy studies, journal articles and policy briefs addressing the rural differential in public policy decision making. He is also a frequent speaker before national and international audiences, having delivered major public policy speeches in over a dozen nations, and has provided senior policy consultation to most federal departments, state and local governments, associations of government, planning and development organizations, and many foundations.

He was a German Marshall Fund Transatlantic Fellow from 2007 to 2011, and recently coordinated a collaboration between former Kentucky Gov. Steve Beshear and U.S. House Appropriations Chairman Hal Rogers to address the severe economic dislocation resulting from the decline in the eastern Kentucky coal industry. His two-year engagement resulted in the establishment of Shaping Our Appalachian Region (SOAR), a public/private/philanthropic intermediary collaborating across 60 counties in the Appalachian mountains.

Revitalizing rural America

The Rural Policy Research Institute is forging innovative collaborations at the rural-urban intersection.


illustration of farming and industry scenesThe prevailing narrative about the rural-urban dynamic is well-known: Rural America is on the decline, while urban America is moving ahead. Residents of rural areas are older, poorer, less healthy, and have lower levels of education than those living in urban regions. Population across rural America is decreasing and the rural economy is struggling. On balance, not an especially optimistic outlook for rural regions.

While structural, demographic, economic, and geographic challenges have seemingly stacked the odds against rural regions, leaders of the University of Iowa-based Rural Policy Research Institute (RUPRI) aren’t buying the stereotypes of “urban growth vs. rural decline.”

Instead, they articulate an alternative view of rural and urban regions as vital, complementary sectors, intrinsically bound together, each essential components of a healthy social, cultural, economic, and environmental whole.

Confronting Common Challenges

Chuck Fluharty, RUPRI president and CEO and clinical professor of health management and policy in the UI College of Public Health, is a passionate proponent of this view of rural-urban interdependence. It is a view, he says, that encompasses the enormous potential for beneficial synergies built on models of regional collaboration.

“Throughout the United States and the world today, people are confronting common challenges, such as the need to develop affordable and appropriate energy systems, including renewables, create functional local and regional food systems, mitigate and adapt to climate change, foster vibrant arts and culture, nurture private civic and social entrepreneurship, and do all this with less, but for wiser public investments,” says Fluharty.

“The rural-urban intersection and regional innovation systems are some of our most important opportunities. Many of the challenges facing modern urban centers depend on rural areas for solutions. Rural citizens steward these resources that urban America needs. So, rural-urban interdependency is our common future.”

Iowa is a microcosm of how America is going to have to address this intersection to craft locally appropriate solutions, notes Fluharty.

“The Des Moines Water Works lawsuit is emblematic of these challenges,” he says, referring to the high-profile legal battle pitting the public water utility of Iowa’s capital city against three rural Iowa counties upstream. At issue is the question of who bears the mounting financial cost to produce clean public drinking water when rivers are heavily polluted by agricultural chemicals and other farm run-off. “These types of challenges require effective regional policy responses, and there are jurisdictional, sectoral, and political dynamics which make all this even more difficult. But these must be overcome.”

Building the Evidence Base for Rural America

The pursuit of effective public policy has been the impetus for RUPRI since it was founded 25 years ago. It was the absence of objective, non-governmental information about rural policy impacts that prompted United States Senate Agriculture Committee members Kit Bond of Missouri, Dale Bumpers of Arkansas, Bob Kerrey of Nebraska, and Tom Harkin of Iowa to establish RUPRI in 1990.

Over the past quarter century, RUPRI has yielded a trove of research, analysis and consultation, engagement, dissemination and outreach, and decision support tools for policymakers. Initiatives cover the full gamut of the rural experience – from health and human services policy to arts and culture, regional innovation and governance, entrepreneurship, poverty, transportation, telecommunications, and wealth creation. (See for more on RUPRI’s areas of work.)

RUPRI has led innovative economic development initiatives seeking to diversify the economy of hard-hit rural areas, such as the coalfields of eastern Kentucky. Its health policy experts are helping rural providers adapt to changes in health care finance and delivery, including telehealth programs. Arts partnerships strengthen rural culture and community. A RUPRI panel is working to improve health and human services delivery models. And by focusing on comparative policy assessments, through collaborations with entities such as the Organisation for Economic Co-operation and Development, RUPRI brings its rural research and policy innovation expertise to the international arena.

The work taking place within this remarkably diverse portfolio is carried out by a core team based in Iowa and Washington D.C., and a number of joint initiatives and panels comprised of colleagues from universities, policy institutes, and organizations across the United States. Funding is primarily through federal grants from agencies such as the U.S. Department of Health and Human Services, the U.S. Department of Agriculture, and the National Endowment for the Arts, among others.

“The breadth of the RUPRI portfolio across multiple sectors, coupled with its extraordinary analytic and research expertise, makes it an invaluable resource for understanding the experiences of rural populations and the complexity of rural issues,” says Sue Curry, dean of the UI College of Public Health. “This is why so many policymakers rely on RUPRI and it’s why it adds such tremendous value to the University of Iowa and the College of Public Health.”

Valuing Rural Culture

Beyond simply building the evidence base to inform sound public policy, however, Fluharty and RUPRI have staked a commitment to the unique value of rural places and the contribution that rural life and culture makes to America’s national identity. Whether through testimony before Congressional committees, advocating for greater private philanthropic investments in rural America, or presenting research findings and recommendations, the RUPRI leadership team is focused on changing the rural-urban narrative to one that appreciates the intrinsic value of rural America.

“Since our nation’s founding, rural areas and rural people have provided the food, fuel, and fiber for all our citizens,” Fluharty says. “Today, as never before, the health, welfare, and future viability of urban America are directly linked to the wellbeing of rural America.”

This article originally appeared in the Fall 2015 issue of InSight.

RUPRI studies rural communities, independently owned pharmacies

Small, independently owned pharmacies play a broad role in health care delivery in rural areas and provide essential clinical services such as blood pressure monitoring, immunizations, and diabetes counseling. Unfortunately, many of these pharmacies are at risk of closure due to the adverse effects of Medicare Part D negotiated networks on their financial viability.

Researchers from the UI College of Public Health’s Center for Rural Policy Analysis (RUPRI) recently analyzed the rural populations served by these pharmacies, as they are most at-risk to lose access to some of these essential clinical services. Understanding the characteristics of this vulnerable population may be useful for proposing policy changes.

According to the research team, in 2014 more than 2.7 million people lived in 663 rural communities served by a sole independently owned pharmacy, and more than one-quarter of these residents (27.9 percent) were living below 150 percent of the federal poverty level. More than 19 percent of them were above age 65, while more than 35 percent of residents were dependent on public insurance or were uninsured.

For a majority of these rural communities, the next nearest pharmacy is more than 10 miles away, which creates access problems for these populations since they are also those most likely to experience barriers to travel (i.e., low-income, publicly insured, and aged 65 years and older). Consequently, loss of a sole, independent pharmacy may deprive many of these rural community members of access to essential clinical and pharmacy services, even if they can continue receiving medications through other means such as mail order or delivery from another location.

Read the full RUPRI policy brief.

RUPRI paper provides model for affordable, accessible health care in rural communities

Keith Mueller
Keith Mueller

A high performance rural health care system, incorporating principles of affordability, accessibility, community focus, high quality, and patient centeredness, could be built upon existing rural primary care services, according to new policy paper from the Rural Policy Research Institute (RUPRI) Health Panel.

“There are growing concerns about the current and future state of rural health care,” says Keith Mueller, Ph.D., chair of the health panel and head of the Department of Health Management and Policy in the University of Iowa College of Public Health. “Health care systems in rural America face disadvantages that their larger, urban counterparts do not, namely disproportionally ill and disabled citizens, under-financed primary care, and geographically isolated providers.

“We believe that a high performance rural health care system, informed by the needs of each unique rural community, will lead to greater community health and well-being,” Mueller says.

In the paper and accompanying brief, “Advancing the Transition to a High Performance Rural Health System,” the RUPRI Health Panel recommends a range of alternative approaches to achieve a high performance health care system, and builds on the panel’s earlier work that conceptually defined the core elements of such a model.

“We previously described where we ought to be in terms of rural health care,” continues Mueller. “We must now take it a step further and explain how we get there – offering strategies and options for creating a pathway to a transformed, high performing rural health system.”

The panel categorizes approaches to achieve its goal of an improved health system into four basic groupings: community-appropriate health system development and workforce design; governance and integration approaches; flexibility in facility or program designation to care for patients in new ways; and financing models that promote investment in delivery system reform.

In addition, each of the four approaches includes a brief discussion of policy considerations and comments about demonstration ideas that can further these approaches.

The RUPRI Health Panel was established in 1993 to provide unbiased analysis and information on the challenges, needs, and opportunities facing rural America. RUPRI’s aim is to spur public dialogue and help policymakers understand the rural impacts of public policies and programs. RUPRI’s reach is national and international and it is one of the world’s preeminent sources of expertise and perspective on policies impacting rural places and people.

Funding for this project was provided by The Leona M. and Harry B. Helmsley Charitable Trust.

This story also appeared in Iowa Now and ASPPH Connect.