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Rural Health Information Hub

Rural Health Policy

How do we ensure access to affordable, high-quality healthcare for rural residents? How can Medicare and Medicaid reimbursement methods allow rural healthcare facilities to keep their doors open? How can we attract healthcare providers to rural communities? These questions, along with countless others, are the basis of rural health policy.

Rural health policymaking takes place at the federal, state, and local levels of government. The process includes identifying and defining a problem, collecting data, researching solutions, choosing a course of action, implementing the plan, and evaluating the results. During each step, policymakers must weigh economic, political, social, legal, ethical, and administrative factors. Formulating rural health policy involves many people and organizations, including:

  • Lawmakers and elected officials
  • Government agencies
  • Health insurers and other payers
  • Membership associations
  • Rural health researchers
  • Rural healthcare providers
  • Rural patients
  • Rural individuals, community-based organizations, businesses, and other stakeholders

These groups work individually and collectively to identify improvements to the provision of healthcare services in rural communities.

Frequently Asked Questions

What types of issues does rural health policy address?

Rural health policy addresses many of the same issues as the broader realm of health policy, such as access to care, quality improvement, cost containment, and healthcare system redesign. However, rural health policy focuses on how policy choices affect rural communities, populations, providers, and healthcare facilities. Health policy issues of interest for rural stakeholders include:

It is important to remember, however, that policy issues change over time. As one problem is addressed through policy channels, other problems persist and new issues emerge. Priorities may shift when there is a change in the political leadership. Changes in public sentiment also play a role in determining which issues receive attention over time.

What role does the federal government play in the rural health policy process?

At the federal level, the executive, legislative, and judicial branches of government conduct the formal policymaking process.

  • Executive Branch
    Headed by the President of the United States, the executive branch plays a strong leadership role in the policymaking process. The executive branch is charged with executing and enforcing the laws as passed by Congress. Executive departments and agencies assist the President in carrying out the daily administrative tasks of the federal government. Through the annual executive budget process, the President is able to set national spending priorities. How the President chooses to allocate resources during his/her tenure can have a major impact on rural healthcare. Another important role of the executive branch is the rulemaking process, which allows federal agencies to determine how laws and policies are interpreted and implemented after receiving public input on proposed rules.
  • Legislative Branch
    The legislative branch of government, or Congress, is composed of two chambers: the U.S. House of Representatives and the U.S. Senate. Elected representatives within each chamber carry out the formal legislative process at the federal level. All federal legislative powers are granted solely to Congress. Congress also holds the “power of the purse,” controlling federal government spending through the appropriations process. At least 11 committees between the House and Senate have some influence over various aspects of rural health policy. The informally organized, bipartisan Senate Rural Health Caucus and Congressional Bipartisan Rural Health Caucus help focus legislative attention and provide a forum for addressing rural healthcare issues. Several agencies within the legislative branch, such as the Congressional Budget Office (CBO) and Library of Congress (LOC), provide support and information services to members of Congress.
  • Judicial Branch
    Composed of the Supreme Court of the United States and other federal courts, the judicial branch interprets the meaning of laws, applies laws to specific cases, and determines the constitutionality of legislation and regulations. Decisions issued by federal courts sometimes affect health policy and rural healthcare in substantial ways.

What is the role of the Federal Office of Rural Health Policy (FORHP)?

Operating within the Health Resources and Services Administration (HRSA), the Federal Office of Rural Health Policy (FORHP) was created by Section 711 of the Social Security Act in 1987, and is charged with the following tasks:

  • Inform and advise the Secretary of the U.S. Department of Health and Human Services (HHS) on matters affecting rural healthcare and hospitals.
  • Coordinate activities within HHS that relate to rural healthcare.
  • Establish and maintain a rural health information clearinghouse.
  • Administer grants, cooperative agreements, and contracts to provide technical assistance and other activities that support healthcare in rural areas.

In this capacity, FORHP serves as a voice for rural communities in federal actions related to health and healthcare. Another primary function of FORHP is providing management and support services for the National Advisory Committee on Rural Health and Human Services (NACRHHS). NACRHHS is a 21-member panel of rural experts that provides recommendations to the Secretary of HHS on issues related to rural health and human services.

Which federal agencies participate in the rural health policy process?

Along with the Federal Office of Rural Health Policy (FORHP), the following agencies work to address rural health policy issues:

U.S. Department of Health and Human Services Agencies

Other Executive Branch Departments and Offices

Independent Congressional Agencies

  • Medicaid and CHIP Payment and Access Commission (MACPAC)
    Operates as a 17-member, independent congressional agency that advises the U.S. Congress on issues affecting Medicaid and the Children's Health Insurance Program (CHIP), including reimbursement policy.
  • Medicare Payment Advisory Commission (MedPAC)
    Operates as a 17-member, independent congressional agency that advises the U.S. Congress on matters affecting the Medicare program, including reimbursement policy.
  • U.S. Government Accountability Office (GAO)
    Examines government spending and services and provides Congress and federal agencies with independent, objective, and reliable information to help the government save money and improve program performance.

How does the rural health policymaking process work?

An issue or idea related to rural health may emerge through research findings or concerns expressed by groups or individuals. Oftentimes, membership organizations bring awareness to issues in the public arena. There are countless ways in which an issue may come to the forefront, and rarely do two policies follow the exact same path.

At the federal level, once a problem and potential policy solution are identified, policymakers in the U.S. Senate and U.S. House of Representatives may craft legislation intended to address the issue. This legislation development process often includes input from a variety of experts and interested parties, including through Senate or House committee hearings, where witnesses invited for their expertise or viewpoint provide testimony and answer questions. To increase the likelihood of getting passed, rural health legislation commonly becomes part of a larger bill, such as an appropriation bill or omnibus package. If the legislation is passed, signed by the President, and becomes law, then federal agencies with jurisdiction over the policy or program will be called upon to administer regulations and enforce the law.

Occasionally, the President may issue executive actions to implement policy. On the federal level, executive orders are often instructions directing federal agencies to conduct certain policy actions and are published along with regulations in the Federal Register.

State-level policymaking involves many players. Policies become law once approved by the state's legislative body and signed by the state's governor. Regulation and enforcement of state-level policies becomes the responsibility of state agencies, similar to the process at the federal level. However, due to a level of state sovereignty as defined by U.S. law, variation amongst enforcement methods exists between states. Table 4.5 in the Council of State Governments' The Book of the States provides a state-by-state overview of the powers of governors to issue executive orders.

At both the state and federal levels, the process of identifying and addressing issues through policy is iterative. Each time a change is made, policymakers, researchers, and interested parties examine the results, look for ways to improve the solutions, and begin the process again. Evaluation and data reporting requirements for federally-funded programs and rural health research help support this process.

How do researchers support rural health policy?

Rural health researchers focus their efforts on identifying, understanding, and solving problems related to the provision of healthcare in rural communities. Research findings help inform policymakers and stakeholders about disparities or other prevalent issues and unique healthcare challenges in rural areas that should be addressed. Additionally, research related to rural populations and rural healthcare facilities helps forecast the effects of policy on rural healthcare access and predicts potential unintended consequences of proposed policies.

Researchers may also be tasked with evaluating program performance. In this role, researchers identify which programs and methods are effective, and which are not. The evaluation process helps to discover and facilitate best practices and ensures resources are being used in the most effective manner.

Through the Federal Office of Rural Health Policy, the federal government funds several rural health research centers and analysis initiatives across the U.S. For information about current rural health research projects, please see the Rural Health Research Gateway. For additional information about conducting rural health research, see the Conducting Rural Health Research, Needs Assessment, and Program Evaluation topic guide.

What role do membership organizations play in advocating for rural health issues?

Membership organizations work with policymakers to inform them on issues and challenges affecting the rural health community. These organizations often communicate important messages by developing policy proposals, producing documents, sponsoring or attending conferences, maintaining an online presence, and communicating directly with lawmakers and regulators. Membership organizations also keep their members informed by tracking pending legislation and regulations. When new laws pass and regulations are issued, membership organizations relay important provisions to ensure their members are aware of the policy change.

As part of their advocacy function, membership organizations mobilize their members and connect them with state and federal legislators. State associations play an important role in educating and advocating for state action and help inform national associations about the implications of national policies at the state and community level. Oftentimes, as a way to focus efforts and set priorities, groups of individuals with similar interests assemble within an organization to form an interest group or committee. This model allows diverse interests to voice their opinions, while working towards common goals within the framework of the larger organization. Other major functions of membership organizations include professional and public education, policy formation, research, and technical assistance.

Membership organizations with interests in rural health include:

  • AARP
    Works at the national, state, and local level on issues important to aging, such as access to adequate, affordable healthcare. Conducts research and publishes reports on topics impacting older adults.
  • American Academy of Family Physicians (AAFP)
    Represents the interests of family physicians, including those working in rural areas.
  • American Hospital Association's Rural Health Services
    Represents and supports America's small and rural hospitals through advocacy, communication, education, technical assistance, and policy development and analysis.
  • American Medical Association (AMA)
    Represents physicians, research, and the history of medicine. Works to ensure sustainable physician practices, improve health outcomes, and accelerate change in medical education.
  • American Public Health Association (APHA)
    Works to improve the health of the public by influencing federal policies and setting priorities in public health.
  • Association of State and Territorial Health Officials (ASTHO)
    Represents public health agencies and professionals in the U.S.
  • National AHEC Organization (NAO)
    Works to enhance access to primary and preventive care, especially in underserved communities, by improving the supply and distribution of healthcare professionals through educational partnerships. Represents more than 300 Area Health Education Center (AHEC) programs nationwide.
  • National Association for Rural Mental Health (NARMH)
    Provides a forum for rural mental health professionals, consumers, and advocates to identify issues, share models and innovations, and inform state and national rural mental health policy.
  • National Association of Community Health Centers (NACHC)
    Focuses on improving and expanding America's network of community health centers through advocacy, technical assistance, training, and research. Primary goal is to improve healthcare access for the medically underserved and uninsured.
  • National Association of County and City Health Officials (NACCHO)
    Focuses on serving local health departments through networking, offering programs and resources, and supporting effective public health systems and practices.
  • National Association of Rural Health Clinics (NARHC)
    Works with Congress, federal agencies, and other rural health stakeholders to improve, promote, expand, and protect the Rural Health Clinic program.
  • National Organization of State Offices of Rural Health (NOSORH)
    Provides technical assistance and support to enhance the capacity of State Offices of Rural Health, with the goal of improving access to, and the quality of, rural healthcare.
  • National Rural Health Association (NRHA)
    Advocates to Congress, the White House, and federal agencies on behalf of rural America. Leads nationwide rural health efforts related to policy, education, advocacy, and communication.
  • State Rural Health Associations
    Organizes and focuses rural health efforts within the individual states.
  • USAging
    Builds the capacity of Area Agencies on Aging and Title VI Native American aging programs to help older adults and people with disabilities live in their homes and communities for as long as possible.

What resources are available to stay current on evolving rural health policy?

Several government agencies, membership organizations, research centers, and nonprofit organizations at the national and state levels serve as resources to stay current on rural health policy issues. The following lists, while not exhaustive, include resources representing a variety of rural health interests:

Resources on Federal Policy

Resources on State Policy
Note: there will be variation among states.

  • State Offices of Rural Health (SORHs)
    State-level offices coordinate statewide efforts to improve healthcare delivery systems in rural communities. They are also tasked with collecting and disseminating information and providing technical assistance to public and nonprofit entities. All 50 states currently have a SORH.
  • State Rural Health Associations (SRHAs)
    Advocacy groups that focus statewide efforts and provide forums for collaboration within each state.
  • State and Regional Primary Care Associations (PCAs)
    Organizations that offer training and technical assistance (T/TA) to safety-net providers.
  • State and Territorial Health Officials
    Oversee state/territorial health departments and implement state laws affecting them. Often lead or serve on boards and commissions related to public health issues.
  • State Long-Term Care Associations
    Trade associations that work to enhance long-term care services through advocacy, education, and collaboration.

How can I influence rural health policy?

There are many ways to engage in the rural health policymaking process. Many membership organizations help their members connect with state and federal legislators and ask their members for feedback on policy priorities and proposals. Writing op-eds in a local paper, attending a public meeting hosted by lawmakers, and hosting visits for lawmakers at your facility are other ways to make government officials aware of current issues affecting your facility or the health of people in your community.

Federal agencies post drafts of new or revised regulations in the Federal Register and often accept comments from the public before the final rule is published. Interested stakeholders, from membership organizations to corporations to individuals, can submit letters describing their concerns of how the proposed rules will impact their interests and/or voice support of these policies. Your Voice is Needed: How to Share Your Perspective on Federal Government Forms, a publication from the Office of Management and Budget, outlines how members of the public can provide feedback on federal information collections. Agencies also post information on public meetings and requests for nominations for advisory committees in the Federal Register. Similar opportunities to comment on proposed regulations exist at the state level as well.

Last Updated: 2/22/2024
Last Reviewed: 2/2/2024