October 16, 2020

After Manchin Urging, Dozens Of West Virginia Rural Health Providers Will Soon Be Eligible For Funding

Charleston, WV – Today, U.S. Senator Joe Manchin (D-WV) submitted comments to the Health Resources and Services Administration (HRSA) on the proposed changes to their rural classification methodology, which determines a large percentage of grants and awards for rural health providers in West Virginia. This revision includes changes for Boone, Clay, Hampshire, Lincoln, Preston and Wirt counties from “urban” to “rural”. Senator Manchin also urged HRSA to include Fayette County in this revision.

Senator Manchin said in part, “I appreciate the opportunity to comment on the Health Resources and Services Administration (HRSA), Department of Health and Human Services (HHS) proposed Revised Geographic Eligibility for Federal Office of Rural Health Policy Grants. HRSA’s Federal Office of Rural Health Policy (FORHP) establishes methods of defining rural areas in the United States to receive services funded by its rural health grant program. These funds are instrumental to providing access to quality health care and health professionals in rural communities across the country. I appreciate HRSA addressing concerns expressed by stakeholders to ensure that rural is properly defined across the United States, especially in West Virginia.”

Senator Manchin successfully included language in Fiscal Year 2020 Appropriations, directing the Economic Research Services and FORHP to work on developing an update to their rural classification methodology. On September 23rd, HRSA released a proposed rule updating their methodology for determining what is “rural”. The methodology is based on economic and geographic measures known as the Rural-Urban Commuting Areas (RUCA) Codes. Under the current classification, 20 counties in West Virginia are labeled “urban” including counties like Preston and Boone, making health providers in these counties ineligible for rural grants and assistance.

The Federal Office of Rural Health Policy is the agency in charge of promoting health services in rural America. It issues millions of dollars in grant funding to critical programs including black lung/coal miner clinics programs, rural opioid response programs, rural HIV/AIDS planning programs, rural telehealth programs, State Offices of Rural Health, hospital flex grants, and many more.

To view a map of current West Virginia county classifications, please click here.

The Senator continued, “West Virginia is the only state that lies completely within the Appalachian Mountain region. It also has a higher mean elevation than any state in the east. According to the Census Bureau, West Virginia is the third most rural state in the nation with 51.8% of the state’s population living in rural areas. West Virginia has 52 Rural Health Clinics, 28 Federally Qualified Health Centers and 3 Look-Alike Organizations (including 390 satellite sites, 179 of which are School-Based Health Centers), and 6 free clinics. Additionally, there are 59 licensed hospitals in West Virginia, including 21 Critical Access Hospitals. However, several of West Virginia’s Critical Access Hospitals, Rural Health Clinics, and other rural providers lie in counties HRSA has designated as urban. I find this concerning, as these critical providers have been ineligible for necessary FORHP grant opportunities.”

Read the full letter below or click here.

 

Dear Administrator Engels:

I appreciate the opportunity to comment on the Health Resources and Services Administration (HRSA), Department of Health and Human Services (HHS) proposed Revised Geographic Eligibility for Federal Office of Rural Health Policy Grants. HRSA’s Federal Office of Rural Health Policy (FORHP) establishes methods of defining rural areas in the United States to receive services funded by its rural health grant program. These funds are instrumental to providing access to quality health care and health professionals in rural communities across the country. I appreciate HRSA addressing concerns expressed by stakeholders to ensure that rural is properly defined across the United States, especially in West Virginia.

West Virginia is the only state that lies completely within the Appalachian Mountain region. It also has a higher mean elevation than any state in the east. According to the Census Bureau, West Virginia is the third most rural state in the nation with 51.8% of the state’s population living in rural areas. West Virginia has 52 Rural Health Clinics, 28 Federally Qualified Health Centers and 3 Look-Alike Organizations (including 390 satellite sites, 179 of which are School-Based Health Centers), and 6 free clinics. Additionally, there are 59 licensed hospitals in West Virginia, including 21 Critical Access Hospitals. However, several of West Virginia’s Critical Access Hospitals, Rural Health Clinics, and other rural providers lie in counties HRSA has designated as urban. I find this concerning, as these critical providers have been ineligible for necessary FORHP grant opportunities.

Specific Comments

Inclusion of Outlying MSAs with No Urban Areas

The proposed change to the rural methodology would list outlying Metropolitan Statistical Area (MSA) counties with no Urban Area (UA) populations to the list of eligible areas. This change would affect six counties in West Virginia including: Boone, Clay, Hampshire, Lincoln, Preston and Wirt. I am extremely supportive of this change.

By including these six counties as rural, health providers will be able to apply and compete for FORHP grants. Prior to the COVID-19 pandemic, nearly half of all rural hospitals were operating at a loss and rural closure rates were escalating dramatically.  Today, these already financially fragile hospitals face catastrophic cash shortages.  Many have furloughed staff, instituted massive cuts, or are shuttering their doors. Any and all resources available to these facilities will not only help stabilize their financial infrastructure but allow them to expand to better serve their patients.

This is a long overdue change for these six counties and I appreciate the recognition that proximity to a metro area does not mean a county is not rural. In fact, West Virginia is uniquely located between several large MSAs, but only has roughly 1.8 million residents. Our population density is only roughly 44 people per square mile, and our largest city is less than 50,000 people.

Providing Exception for Mountainous/Difficult Terrain

While I appreciate the update to include counties in MSAs with no UAs, I believe that FORHP is still missing the mark when it comes to measuring rurality in West Virginia. Currently the USDA Economic Research Service (ERS) has developed Rural-Urban Commuting Area (RUCA) codes to define labor commuting of rural populations and the Frontier and Remote Area Codes to measure sparsely settled and remote areas, however an adequate measure for sparsely populated mountain regions, and commuting times for difficult terrain are not adequately measured. Compounding this issue, we have a deficiency of high-speed internet access due to the terrain, making delivery of health care through other means, such as telehealth, even more difficult.  While many sites are trying to adopt telehealth services, the mountainous region often makes technology infrastructure inaccessible and unreliable.

In particular, Fayette County in West Virginia should be included as rural for purposes of FORHP grant eligibility.

Fayette County is home to just over 42,000 residents, the New River, New River Gorge Bridge, and hundreds of miles of hiking and biking trails. Fayette County sees over a million visitors each year to explore its scenic landscape. Its largest city is Oak Hill, which only has about 8,000 residents, well under the definition of Micropolitan area. Fayette County is served by two Critical Access Hospitals - Plateau Medical Center and Montgomery General Hospital - New River Health centers, including school-based health centers, and several other health providers. The unique landscape of West Virginia, and in particular Fayette County, reflects the need for additional exceptions for mountainous or difficult terrain. In areas like Fayette County, the density per square mile is higher than you would find in a larger geographic landscape, where travel by road is on primary roads over flat terrain. Travel through the secondary roads and mountainous terrain of West Virginia makes access to health care more difficult, and requires health providers be more closely located to ensure patients are served in a timely manner, especially for emergent health concerns.

Currently FORHP provides exceptions to census tracts with a RUCA codes of 2 or 3 that are “400 square miles in area with a population density of no more than 35 people per square mile”. FORHP should consider including an exception aimed at the Appalachian region, which is a highly mountainous and rural region. The Centers for Medicare & Medicaid Services (CMS) recognized the need to provide a shorter distance requirement for rural areas in mountainous terrain with a lack of primary roads, and requires critical access hospitals to only have 15 miles to the next nearest like facility, instead of the required 35 miles.

Fayette County is not included in this recent change due to UAs from Charleston and Beckley reaching into part of the county. However, these UAs only take into account density per square mile, and not the terrain where you may find a higher density, but longer commuting times. The topography of Fayette County and its largest city only having 8,000 residents, support Fayette County being included as rural for purposes of FORHP grants.

Hub Sites That Serve Majority Rural Population

(We/I) would also like to encourage FORHP to consider expanding eligibility to health centers that primarily serve rural populations but may be connected to a hub site located in an MSA UA. Several health centers located in rural counties in West Virginia, have a hub site registered inside a nearby county that FORHP considers “urban”. Several of these satellite sites serve a majority rural population and provide critical health services. For purposes of applying for grants, FORHP requires centers apply through their primary location, which is often their hub site, and not the location where services are rendered. FORHP should review this criterion and consider allowing health centers with service sites that serve a majority rural population be eligible to apply for grants based on the location of the service being rendered.

Thank you again for the opportunity to comment on this notice. If you have any questions regarding our comments, please contact my office at 202-224-3954.