This is the final installment in a four-part series identifying policy reform opportunities that could improve the quality of life for rural Americans.

How open is healthcare in your state? How much discretion do patients, providers, and medical institutions have in determining how care will be delivered? People often misattribute America’s healthcare access problems to federal policy or insurance bureaucracy. In truth, state healthcare laws, regulations, and customs play a significant role in how easily their residents can access and pay for care.

The Mercatus Center’s Healthcare Openness and Access Project (HOAP) quantifies and compares healthcare openness and accessibility by providing state-by-state datasets on the “flexibility and discretion US patients and providers have in managing health care.”

State policymakers can view HOAP’s 38 indicators—ranging from how states reimburse telemedicine providers to the scope of practice afforded to nurse practitioners—to see how their own states’ openness compares to the rest of the country. State health policies that are more open and accessible tend to better serve the care needs of their populations.

Some of these policies have a disproportionate impact on rural communities, many of which already have access difficulties due to their remote location. State policies that prohibit innovative medical developments will make it all the harder for remote populations to access care.

Mercatus scholars have a host of state reform ideas that could improve medical access for rural areas, which we will discuss while offering links to more information.

What Do We Mean by Openness and Access?

“Openness” and “access” have positive connotations. But not all “openness” is created equal, and sometimes “access” can be a bad thing. For example, most people would think it is a good thing that we do not have “access” today to Radithor—a medically useless radium-based patent medicine that famously led to a socialite’s horrifying death by radiation poisoning in 1932.

It is helpful to think about openness and access in terms of the distinction between “good barriers” and “bad barriers.”

Driving is a good illustration. Obviously, we want our roads to be open and accessible. Putting up arbitrary concrete walls in the middle of the road would make a bad barrier. But we need the roads to be safe and usable, too. So we erect good barriers, like medians in the middle of a two-way road that prevent one stream of traffic from colliding into the other.

The same is true with healthcare. We want to minimize the number of random concrete walls that merely interfere with the normal flow of “traffic.” But we want to keep and shore up the good barriers that make our healthcare system safe and effective.

Unfortunately, there are many “bad barriers” in healthcare that diminish openness and access for vulnerable populations—particularly those in hard-to-reach locations. Here are just a few, along with some ideas for reform.

1) Allow and Encourage Telemedicine

Physical distance is one barrier to healthcare access. People who live far away from city centers may have to travel far to reach the nearest healthcare provider. This problem is exacerbated when the ratio of healthcare providers to the population is already poor.

(While this essay focuses on rural areas, we’ll note in passing that access can be problematic for travelers, for people in poorer urban neighborhoods, for those whose jobs and daily routine make medical appointments difficult, and for elderly people and others with mobility challenges.)

It’s inconvenient enough to have to drive several hours to visit your doctor for a normal checkup. This annoyance could dissuade people from regular check-ins with their primary care doctor, leaving potential health problems undetected. In the case of a medical emergency, the lack of immediate healthcare services can be a matter of life and death.

Telemedicine is one tool that healthcare providers have to bridge the access gap for remote populations.

Telemedicine allows patients to connect directly with doctors through the use of internet teleconferencing. Patients can download an app, describe (or even show) their symptoms to a faraway doctor over video, and receive a diagnosis or prescription. Though not yet widely used, inexpensive diagnostic devices like stethoscopes can be plugged into smartphones, tablets, or laptops to aid the remote doctor. A smartphone can also be used to check the heart for an arrhythmia, sending the EKG report to the doctor. For more complex or dangerous maladies, the doctor will refer the patient to an emergency care clinic.

Telemedical visits can be much more affordable than in-person visits, saving patients money. They can also be offered outside of the standard nine-to-five workday window, offering patients more flexibility to schedule appointments.

Telemedicine, therefore, gives rural populations an intermediate option before being forced to drive long distances—perhaps in the middle of the night—for an ailment that might only turn out to be an upset stomach. It can also be a life-saving directive to seek urgent care for people who otherwise would wait to see whether their truly dangerous symptoms just “go away” on their own.

Unfortunately, state policies can undermine the promise of telemedicine. For example, some states have limited telemedical visits to doctors whom a patient has visited in person. Other states require a telepresenter—a healthcare provider, like a nurse—to be present with the patient during the call. Such laws have the effect of raising the monetary and nonmonetary costs of telemedicine, greatly reducing the impact of this medical innovation.

State policymakers looking to improve healthcare access for rural constituents should review the laws that limit telemedical access on their books. The Mercatus Center’s HOAP index provides a handy tool that lays out how each state’s policies affect access to telemedicine. Removing any barriers could greatly improve rural communities’ access to intermediate medical care.

2) Scrutinize Scope of Practice Laws

Scope of practice laws are another factor that can artificially increase the physical distance between patients and healthcare providers.

As mentioned earlier, rural populations sometimes have to drive long distances to visit the nearest hospital or general practice provider. This may be more justifiable for specialty care, where in-person diagnostic tools and methods may be more important. But long excursions to treat a run-of-the-mill malady like a sore throat are harder to tolerate, leading some to unnecessarily suffer.

Common and easy-to-treat problems could just as effectively be tended to by knowledgeable healthcare providers like nurse practitioners and physician assistants. Yet scope of practice laws in many states prohibit such providers from treating patients without physician supervision. (On the other hand, many states do grant such autonomy to nonphysician providers, with no obvious ill effects to those states’ patient populations.)

Scope of practice laws, which limit what non-doctor medical providers can do, are often justified on the basis of safety. But research suggests that nurse practitioners and physician assistants provide a broad range of basic primary care services just as safely and competently as physicians—and are fully aware of which situations require a doctor. Nonphysician providers are generally more affordable as well, and can greatly expand the availability of basic care in hard-to-reach places.

State policymakers who want to champion healthcare access in rural communities should consider reviewing their scope of practice laws to determine whether they create needless barriers to safe, affordable care. Expanding the supply of healthcare providers who are legally allowed to treat common ailments would greatly improve the menu of options available to those in rural areas.

3) Consider Certificate-of-Need (CON) Law Reform

States also hinder rural healthcare access by tightly controlling which new healthcare services can be provided. In 35 states and the District of Columbia, healthcare providers cannot legally provide new services (e.g., more beds in a hospital, a new CT scanner, an ambulance service) until their state’s department of health approves what is called a “certificate of need” (CON) based on whether those authorities perceive a “tangible need” for expanded care. Filing for a certificate of need is expensive and time-consuming; these regulations effectively diminish access to medical services, and rural communities suffer as a result.

When Danny Meyer, founder of Shake Shack, set out to open his first restaurant in 2004, it wasn’t self-evident that New York City needed another burger place. Meyer analyzed the market, perceived an opportunity for his dining concept, and launched the chain. Had he detected a need for a new medical clinic, he would have first been obligated to demonstrate to the New York Department of Health that the community in which he wished to open the clinic had a need for it.

Rural areas are disproportionately affected by CON laws. The regulatory offices’ control over the supply of healthcare services can result in additional driving time, with potentially dramatic consequences for patients.

Take the tragic story of this mother, who, for lack of a neonatal intensive care unit (NICU) in the facility where doctors were giving her emergency care, lost her baby. The hospital, located in Salem, Virginia, had placed an application for an NICU two years earlier, but the request was rejected by the state Department of Health on grounds that the new service would needlessly duplicate a service that was already provided by a hospital in Roanoke, six miles away. This rejection occurred despite overwhelming popular support of the project by a variety of non-healthcare officials, business people, and citizens. It appears that the individual who led the opposition to the request had ties to the hospital with the existing NICU, which suggests CON laws often aren’t used for the good of the community but rather to serve special interests.

As such, CON laws give undue power to officials to determine what the community needs and affect the lives and health of patients in rural areas. State policymakers who wish to move the needle on this issue can find the Mercatus Center’s resources on the topic here.

Removing “Bad Barriers” to Improve Rural Healthcare Access

Laws that dissuade telemedicine, nurse practitioner and physician assistant care and the free operation of needed services are often harmful barriers that severely limit the care that rural populations can access.

Healthcare policy is generally categorized as a federal issue. Many times, reform-minded state policymakers are simply unaware that these barriers are, in fact, bad—and well within their powers to correct.

Our scholars created the HOAP index to shed light on how state policies affect the provision and access to care. Lawmakers now have the tools to identify exactly which bad barriers may stand in the way of affordable healthcare access. Peeling them back will greatly improve rural constituencies’ options to receive the care they need.

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