Rural health care’s quarter-century transformation
Middleton’s bipartisan legislation pushed the health needs of rural communities to front at the State House
Over the last 25 years, Maryland’s General Assembly has been gradually turning a legislative spotlight toward an issue that until then had been largely invisible: ensuring that the state’s rural residents have access to the same quality of health care that people in the state’s prosperous urban core have come to expect.
Legislators and advocates credit former Charles County senator Thomas M. “Mac” Middleton as being one of the driving forces behind that turn. In the 24 years that the Democrat served in the Senate — much of it as chair of the all-powerful Finance Committee — the General Assembly passed several landmark bills that strengthened primary care in rural areas, broadened access to dental coverage, and stabilized the state’s wobbly health insurance marketplace. Middleton introduced many of those bills, and those he didn’t still bore his stamp.
As a result of that legislative push, the health outlook for rural Marylanders has greatly improved. Although much remains to be done — and Middleton himself is no longer in office — he expects that the momentum will continue into the foreseeable future.
The need
To quantify the challenge that health care providers face in attempting to deliver services to Maryland’s rural areas, consider that almost 30% of the state’s residents — 1,688,000 as of the 2010 census — live in rural areas.
The Maryland Rural Health Association and the Rural Maryland Council have found that the state’s rural residents have higher rates of chronic illness and poorer overall health, and are less likely to have health insurance, than urban residents.
Rural residents — who are on average older and less affluent — also have fewer primary care doctors nearby to call on because their doctors, too, are aging and retiring and fewer doctors want to open up practices far from urban centers.
Stepping up to meet the challenge
Compared to the rest of the state, “Southern Maryland had the most severe shortage of [primary care physicians] when I went to the legislature,” Middleton said. “I was able to take that awareness with me to Annapolis” after serving eight years as the Charles County Board of Commissioners’ president.
After Middleton won his Senate election in 1994, Senate President Thomas V. Mike Miller Jr. (D-Calvert, Charles, Prince George’s) assigned him to the Budget and Taxation Committee, where he was a member of the health subcommittee that ensured health programs like Medicaid received adequate funding.
That year, Middleton and Del. Casper R. Taylor Jr. (D-Allegany) — who had just been named speaker of the house and, like Middleton, was from a rural county — helped establish the Forum for Rural Maryland, which later became the Rural Maryland Council, to help develop and fund strategies for addressing rural issues, including health disparities. They also encouraged the Maryland Health Department to host a conference on rural health that resulted in the establishment of the Maryland Rural Health Association, a nonprofit advocacy and education collaborative that has since taken the lead in developing strategic plans for rural health care.
“The big challenge for rural hospitals has been [that] it’s harder to reach the population that needs care and we lack access to transit,” said Charlotte Davis, RMC’s executive director. “Transportation is a major barrier. We’re overall poorer in rural areas, we have higher rates of poverty. So the social determinants of health kick in a little bit more for rural [populations].”
“He was instrumental in saying that if the patients can’t go to them, well then, we need to figure out how to get to the patients,” Davis said. “He was our champion for that.”
From budget to policy
In 2002, Miller asked Middleton to chair the Senate Finance Committee. That’s when Middleton was finally able to delve into the policy side of health care, a task he relished.
One of the issues that kept coming up in committees and studies was the fact that smaller rural hospitals were increasingly facing a choice of consolidation or closure because of the high cost of operating in less affluent regions of the state.
The solution, or so it seemed, was to pass legislation to allow hospitals to scale back and offer fewer services. The General Assembly passed the bill in 2016, but added a proviso that before they could get approval from the state’s health care commission to downsize, hospitals had to first get the buy-in of community residents.
When the Shore Medical Center in Chester town proposed such a downsizing three years ago, there was an outcry from the people in the five counties it served and the process deadlocked. To help find a solution, last year Middleton cosponsored a bill with Sen. Stephen S. Hershey Jr. (R-Caroline, Cecil, Kent, Queen Anne’s) and former Sen. James N. Mathias Jr. (D-Somerset, Worcester, Wicomico) to establish a pilot project for rural health care called the Mid-Shore Rural Health Collaborative to develop statewide policy for establishing appropriately scaled rural health centers.
The collaborative’s committee will be providing its recommendations to the governor by the end of 2020. Middleton considers the collaborative to be one of his best accomplishments, with the prospect of changing the rural health care landscape in Maryland and even beyond.
“We felt we had the opportunity to create a national model of how to address rural health care needs,” Middleton said.
Middleton was also able to direct attention — and funding — toward resolving other health care issues that disproportionately affected rural Marylanders: health insurance and dental care.
Last year, Gov. Larry Hogan (R) signed emergency bills sponsored by Middleton and Del. Joseline Peña-Melnyk (D-Anne Arundel, Prince George’s) that helped stabilize the state’s health benefits exchange before spiraling costs forced insurance providers CareFirst BlueCross BlueShield and Kaiser Permanente to withdraw from the exchange. As a results, rate increases this year were much more manageable for people of moderate means.
Another bill, which Middleton cosponsored with Sen. Guy Guzzone (D-Howard), established a pilot program to assess the feasibility of covering adult dental services through Medicaid, a move that is expected to reduce emergency room visits for chronic dental conditions and save rural hospitals hundreds of thousands of dollars a year.
Maryland Dental Action Coalition executive director Mary Backley said that the bill’s unanimous passage was due largely to Middleton’s efforts to educate his colleagues about the need to consider oral health as an integral part of overall physical health.
“His colleagues weren’t educated on this,” Backley said. “He helped them make the connection. He teased out questions that he knew his colleagues needed to hear the answers to.”
“It’s a landmark bill and we’re confident that it will eventually lead to Medicaid dental coverage for all Marylanders,” she said.
What lies ahead
Despite those key legislative accomplishments, MRHA executive director Lara Wilson said that rural parts of the state still face critical health care issues that need to be addressed legislatively.
For example, by law emergency medical technicians in Maryland can only receive reimbursement for their services when they deliver patients to a hospital — but rural hospitals are trying to reduce emergency room visits because so many people use ERs for primary care because they either lack insurance or have nowhere else to go.
“EMTs need to be able to be reimbursed for taking a patient somewhere other than a hospital,” Wilson said. “It’s a case of two incentives working against each other.”
Another issue is the need to find ways to attract young primary care doctors to open practices in rural areas.
“We’re trying to bring back the rural residency tracks because there’s a lot of evidence that … providers end up working wherever they do their residency,” Wilson said. “If we can help provide opportunities for doctors, EMTs, and [physician’s assistants] to do their residencies and their clinical work in the rural communities, they might be more likely to stay there afterwards and practice.”
Although Middleton is no longer in the Senate, Hershey and Guzzone and others who worked with him still are. Davis believes that they will have a better chance of addressing those issues if they follow Middleton’s playbook and get people to talk past their political and policy differences to hammer out mutually satisfactory solutions.
“This is about bringing diverse viewpoints together, working out a compromise that everyone can agree on,” Davis said. “We might only get pieces of what we want, but we all walk away satisfied with the outcome.”