CALONGE COMMENTS

Wyoming state senator Charles Scott (R) and Milbank Memorial Fund president Christopher Koller (p. 705) provide an important perspective of the health care policy challenges facing rural Western states, focusing on the key issues of cost and access. The identified areas of cost shifting, provider monopolies, insurer markets, and provider supply provide a good framework for evaluating the problem. Scott and Koller mention a fifth dominant issue—low population density—that spreads fixed costs over a much smaller number of individuals and takes away important cost–access levers such as purchasing economies of scale and large network development. This issue would not be considered a “modifiable factor,” despite Wyoming’s natural beauty and attractive lifestyle.

STATE GOVERNMENT’S ROLE

Does the state government have a role in addressing the other factors discussed? Regarding cost shifting, Wyoming’s nonprofit hospitals embrace their charitable missions, providing not only care undercompensated by public funding but uncompensated care. Strategies that diversify funding sources could help, including Medicaid expansion—Scott is currently supporting legislation to evaluate the costs and revenue of possible expansion.¹ Another strategy is a hospital provider fee, which is paid to the state, matched with federal dollars, and returned to the hospitals through higher Medicaid reimbursements.² This strategy has been important to the survival of rural Colorado hospitals. Wyoming’s concerns about the reliability of federal policy in supporting state needs should not be taken lightly; at the same time, Wyoming citizens pay the same federal taxes, and taking advantage of the system they already support could help address cost issues.

Regulatory approaches to provider monopolies might disenfranchise the medical community, who have options about where they practice. Also recognize, though, that group practices support a more balanced lifestyle for today’s doctors. Although I have deep respect and admiration for those stalwart rural solo practitioners, like my father and grandfather, there is a personal cost to these individuals and their families. Considering programs that support peer interaction and time away from one’s practice are strategies that can support single providers.

The unanticipated impact on insurance markets from defining basic coverage packages under the Affordable Care Act, although intended to ensure that all plans covered essential services, is a point well made. Without addressing costs, providing access for more people to the same high-cost system might be expected to produce the results outlined by Scott and Koller. Because of the current organization of health care, a single state may not have much leverage regarding this issue. However, a key part of insurance economics is the risk pool itself. The individual mandate was designed to spread the cost of care over a larger pool with less risk and utilization. Wyoming’s proud sense of individual freedom and independence is a highlight of Western culture, and at the same time residents are known for coming together when facing shared challenges. An alternative to regulating health behaviors is to address them together as a community who will work for the good of their neighbors. Embracing the Wyoming lifestyle, which respects individual freedom and promotes health behaviors that reduce chronic disease risk, would affect the risk pool and contribute to lower insurance costs. Community-driven public health might be a new lever to consider.

The final issue Scott and Koller listed was provider supply. Wyoming is engaged in many of the strategies to address provider supply, including tuition support, loan repayment, and recruitment grants. There are other strategies, such as scope of practice legislation, whereby Wyoming has authorized prescriptive authority for advance practice nurses and could address pharmacists and certified registered nurse anesthesiologists (the latter under the Medicare certified registered nurse anesthesiologist supervision op-out).

SOLUTIONS

Understanding the root causes of health care costs and access in rural Western states is key to developing solutions, and Scott and Koller’s analysis provides valuable insights. Solutions will have to be developed locally and crafted with recognition of and respect for the culture of the states involved. As libertarian values are shared across many of the states in the Rocky Mountain West, perhaps a final consideration would be to explore regional state partnerships that could address the fixed costs and risk pool issues through cross-border solutions created within a common culture.