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Rural, small town health care: in need of a shot in the arm.

Health care access in small town and rural America is frequently a matter of life and death, not just to the people who live there. It's an issue that cuts to the very survival of many such communities.

Access to good medical care is an imperative for economic development and community growth. Some small towns have even begun to offer bounties to citizens who successfully recruit health professionals to set up practices in small towns particularly those communities that are geographically isolated

What is included in the Clinton Administration Health Care proposal that is particularly applicable to smaller communities in America?

The Clinton Administration plan contains provisions intended to attract medical professionals to small town America and to provide payment to health providers from all who receive care. The administration plan also contains special limits on health care costs for small employers, although these caps are not currently proposed for small town and city governments as employers (see related stories in this issue of NCW). While not currently applicable to cities that are small employers, this provision may be particularly important because the job base of smaller communities is predominantly composed of small employers.

A series of public health initiatives proposed in the plan as well as the coverage under all health plans of preventative services may be of particular value in many rural communities, providing income streams for currently uncompensated or unprovided care and outreach.

The plan also includes a number of sections suggesting ways in which special programs developed by the new regional health alliances can incentivize the provision of health care in rural and underserved areas. Small communities will have to be particularly vigilant as states draw up regional alliance boundaries or decide on a state single-payer plan to make sure that the boundaries will provide appropriate care. In thinly settled states where much health care is obtained across state lines such structural issues will also be very important.

While the plan contains a number of reforms to unprove access and availability there are graphic characteristics that are beyond the ability of the plan to change. It is likely that the choice of health plan options in rural areas will continue to be less diverse than in urban areas even after reform.

Small Cities as Employers: No Special Treatment

Small cities will be required to pay at least 80 percent of the regional alliance health premiums just as with all other cities. As with all other cities they will not be eligible for the 7.9 percent of payroll cap or the special small employers caps which are discussed below. As with all other cities small communities will be required to pay for full family unit coverage and pay premiums for part-time workers on a pro-rata basis.

Employees of small cities in low wage areas will be eligible for a low income subsidy of employee's share of the regional health care premium, if the household income of the employee is less than 150 percent of the federal poverty level.

The federal poverty level for a family of four is currently $21,525.

Incentives to Practice in Small Communities

The Clinton plan promises a number of special incentives intended to improve the provision of medical care in smaller communities.

A special rural health provider grant program is proposed to provide community based training programs for rural providers, develop rural oriented health education curricula and improve medical communications technology.

Health alliances will be encouraged to develop special programs to ensure access by rural underserved populations access to special services.

Academic health centers are proposed for grants to assist development of an information and referral infrastructure to benefit in rural areas.

A series of special tax incentives is proposed to encourage medical practice in rural areas including: a personal tax credit of $1,000 a month for doctors ($500 for physicians assistants and nurse practitioners) during the first five years of practice in a rural area with a shortage of health professionals; a tax allowance of $10,000 per year for the purchase of medical equipment used in underserved areas; and a deduction of $5,000 in student loan interest for medical professionals performing services under agreements with rural communities.

Small Employer Issues

Because small employers are often the job base in many smaller communities the provisions of the plan intended to shield the small employers, many of whom may not currently provide employee health care, from the full impact of the employer mandate contained in the plan, is particularly important.

It is understood that the issue of small employer subsidy is currently under review by the administration and the costs of this program are being reviewed before the Clinton Administration proposal is put in bill form. However, the most recent publicly available drafts of the plan indicate that a small employer subsidy would be made available to all private employers with 50 or less employees, whose average full-time wage is less than $24,000 a year.

For small communities whose major employer is part of a national organization with 5,000 or more employees the local employees of the company may receive coverage through a company plan rather than the regional alliance covering everyone else in the community. This has the potential of creating some inconsistencies in practices which may be particularly visible in "one-employer" communities.
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Title Annotation:includes related information on the Clinton health care reform proposal
Author:Peterson, Doug
Publication:Nation's Cities Weekly
Date:Oct 11, 1993
Previous Article:Human Development unit urges NLC to back Clinton health care proposal.
Next Article:Congress, administration put crime bill on fast track.

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