No Country For Health Care, Part 3: Shrinking Rural Ranks

AUSTIN — Politically speaking, it’s no time to be an advocate for rural health care.  

In the last House Speaker’s race and on the state’s health care regulatory boards, rural lawmakers say they’ve been outnumbered and under-represented. The looming redistricting battle will only shrink their ranks.  

They’re finding it more and more difficult to teach an increasingly urban Legislature about the crisis in rural health care.

“Every seat we lose, that’s one more person we have to convince,” said State Rep. Joe Heflin, D-Crosbyton, whose 15,000-square-mile Panhandle district includes six small rural hospitals and one county with no medical care at all.   “It’s just a giant uphill battle.”

Rural lawmakers felt safe with former House Speaker Pete Laney, whose Panhandle district was undeniably rural. Laney’s successor, former House Speaker Tom Craddick, was seen as an ally too: His Midland district is partly rural, and he appointed rural lawmakers to key committee posts.

But with last session’s election of San Antonio Rep. Joe Straus as Speaker, a big city lawmaker now holds the House’s top post. And urban House members replaced many rural ones as committee chairs, a hit to rural lawmakers’ cumulative influence.

Straus' staffers say though he's from an urban district, he’s committed to strengthening health care delivery statewide. In his interim charges, he asked the House Committee on County Affairs to compare urban and rural health delivery models — and to make recommendations for reducing disparities.

"Speaker Straus listens to and is respectful of the views and concerns of all House members," spokeswoman Tracy Young said.

But Straus’ commitment doesn’t necessarily change the political landscape for rural lawmakers.

Under Craddick, rural lawmakers chaired the House State Affairs and Appropriations committees, two of the most powerful legislative posts. Now, lobbyists for rural Texas say the most influential advocate they have left is Sen. Robert Duncan, R-Lubbock, who represents much of the Panhandle and chairs the Senate State Affairs committee.

They expect to lose even more clout next year, when lawmakers convene and begin redistricting. Health care experts estimate rural Texas will lose up to five Legislative seats — three or four in the House and one in the Senate. This means legislation improving rural health care will fall on fewer sympathetic ears, and that measures threatening rural health care will take more work to defeat. 

Meanwhile, advocates for rural health care say they’ve felt besieged by the state’s medical regulatory boards, which have considered rule changes that are unworkable in rural clinics and hospitals.

“The difference between urban and rural medicine is the difference between an NFL football team and a six-man high school team — one that’s playing offense, defense, and playing in the band at halftime,” said Don McBeath, director of advocacy for the Texas Organization of Rural and Community Hospitals. “Nobody’s against higher standards of care. But we have to make sure we don’t inadvertently put so much burden on the rural providers that they can’t survive.”

Late last year, the Texas Medical Board considered requiring all health care professionals using videoconferencing to treat patients to be licensed as a doctor, a physician assistant or an advanced practice nurse — eliminating rural paramedics and many lower level nurses from the equation. Then the Texas State Board of Pharmacy considered requiring pharmacy technicians to be overseen by licensed pharmacists at all times, either in person, or via videoconferencing.

In both cases, the measures were designed to ensure patients were receiving professional, standardized care, regardless of whether they lived in urban or rural communities. The reality, health care experts say, is that these new rules would’ve restricted access to what little medical care exists in rural Texas. In some counties, EMTs and entry-level nurses are the only health care professionals available. Banning them from explaining a patient’s symptoms to a doctor over videoconferencing makes little sense to rural Texans. And many Texas communities are lucky to even have a part-time pharmacy technician — let alone a pharmacist to oversee that technician. Requiring them to be monitored by a pharmacist at all times is completely unrealistic, these experts say.

Both boards put the rule changes off for further study, following immediate outrage from rural health care providers.

“You scratch your head, because they say they want to promote health care in rural Texas,” Heflin said. “But then they’re doing everything they can to eliminate it.”