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Twenty five years ago, the Texas Legislature passed a sweeping set of reforms to resuscitate the state’s collapsing rural health care system.
Now, health care providers, advocates and local leaders are proposing similarly aggressive action to pull the rural maternity care system back from the brink. The Rural Texas Maternal Health Rescue Plan is a package of proposals they’re hoping lawmakers will champion in this upcoming session.
Almost half of all Texas counties offer no maternity care services, and more than a quarter of rural mothers live more than 30 minutes away from the nearest provider. Living in a “maternity care desert” contributes to delayed prenatal care, increased pregnancy complications and worse delivery outcomes. Women living in rural areas are more likely to die from pregnancy or childbirth-related causes, and infant mortality is also higher.
But despite these sobering statistics, more rural hospitals are closing their labor and delivery units, leaving patients to travel long distances or deliver in under-equipped emergency rooms. Most of those that do still deliver babies lose money in the process, due to low Medicaid payments and too few deliveries to break even on round-the-clock staffing.
“We’re reaching a tipping point where people are frequently more than an hour from routine prenatal care, and more than an hour from a delivering hospital when their water breaks,” said John Henderson, president of the Texas Organization of Rural and Community Hospitals. “There’s no way we’re going to get the kind of quality or outcomes we want as a state when that’s the reality.”
The Texas A&M Rural and Community Health Institute convened more than 40 groups, representing rural hospitals, health care providers, medical schools, advocacy groups and nonprofits, to create this rescue plan. They’ve identified steps the Legislature could take this session, including increasing Medicaid payment rates, incentivizing health care providers to work in rural areas and improving overall women’s health care access.
“I don’t think anyone thinks that we’re going to be able to restore services at the 20 or 30 rural hospitals that closed or suspended their OB programs,” Henderson said. “But if we don’t do something, we’ll see more go the same way.”
Last session, the first since the overturn of Roe v. Wade and Texas’ near-total abortion ban, lawmakers extended postpartum Medicaid to a full year and waived sales tax on diapers and menstrual products. Ahead of this session, House Speaker Dade Phelan listed improving access to rural prenatal and obstetrics care as one of his interim priorities.
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Strengthening access to rural maternity care would be a bipartisan way to show up for moms and babies in Texas, said Tom Banning, CEO of the Texas Academy of Family Physicians.
“There’s not a silver bullet to this. We would have done it if there was,” Banning said. “But we just want to bring forward ideas for them to think about as possible legislation or funding strategies. That’s what this report is intended to do, to give them options.”
“Code Red” proposals
Several of the top priorities focus on Medicaid, the largest payer of maternal health services in Texas. Medicaid pays for half of births statewide, but in rural areas, covers between 60% and 90% of births. Medicaid is primarily federally funded, but states administer the program.
This plan proposes reimbursing rural hospitals based on the actual costs they incur delivering a baby, rather than a set rate, and offering doctors fixed monthly per-patient payments to cover the costs of preventive, primary and maternity care needs. They’re hoping this will make it more financially appealing for hospitals to keep delivering babies, and recruit the health care providers they need to do so.
The state should also make it easier for pregnant women to get on Medicaid, and easier for doctors to start accepting Medicaid, the report says.
“The administrative burden of being in Medicaid is substantial,” Diana Forester, the director of health policy at Texans Care for Children, a health advocacy group, is quoted as saying in the report. “I talked to one OB group outside of Sweetwater that said they’re the only birthing unit for hundreds of miles. And they couldn’t get enrolled in Medicaid so they can’t treat Medicaid patients.”
Last legislative session, lawmakers tackled the growing nursing shortage with scholarships, grants and loan repayment programs, and allocated additional funds for graduate medical education programs in rural and community health. But much more is needed, this report says. The state urgently needs to strengthen loan repayment programs for OB-GYNs, family physicians and other health care professionals who practice in rural areas, and create more opportunities for medical students and residents to train outside of major cities.
This plan also lays out ways the Legislature could shore up rural women’s health care more broadly, ensuring they are healthy before and after pregnancy. As one of 10 states that hasn’t expanded Medicaid, Texas has a 21.7% uninsured rate, the highest in the nation. While lawmakers are unlikely to move on that issue anytime soon, they could allocate more money for state-run programs like Healthy Texas Women, the Family Planning Program and the Breast and Cervical Cancer Treatment Program. They could also pour more money into mobile clinics and federally qualified health centers, safety net clinics that cover un- and under-insured Texans.
In a legislative session focused on hot-button political issues like school choice, immigration and property taxes, the groups that put together the Rural Texas Maternal Health Rescue Plan are hoping to offer common-sense proposals that both parties can get behind, Henderson said. They’ll be pitching these plans to legislators in the lead up to the 2025 session.
“All these other priorities are billion dollar projects. What we’re talking about is maybe $100 million,” he said. “It’s not a showstopper budgetary impact.”
“Rural communities have figured out that if they stand together, they can stretch a dollar a long way,” Banning added. “And in this case, it can be a force multiplier for other opportunities in those communities.”
Disclosure: Texans Care for Children has been a financial supporter of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune’s journalism. Find a complete list of them here.