National Organization of State Offices of Rural Health Issues Public Comment on OMB Notice

WASHINGTON, July 10 -- The National Organization of State Offices of Rural Health, Sterling Heights, Michigan, has issued a public comment on the Office of Management and Budget notice entitled "Methods and Leading Practices for Advancing Equity and Support for Underserved Communities through Government". The comment was posted on July 6, 2021:

* * *

Overview:

On May 5, 2021, the Office of Management and Budget (OMB) issued a Request for Information (RFI) on Methods and Leading Practices for Advancing Equity and Support for Underserved Communities Through Government (86 FR 24029). This RFI reflects the direction of Executive Order 13985, which asks all agencies to explore how their operations can better address the inequalities and disparities faced by key subpopulations. In this communication, the National Organization of State Offices of Rural Health (NOSORH) addresses the questions raised in the RFI and makes comments on approaches for advancing equity.

NOSORH was established in 1995 to assist State Offices of Rural Health (SORHs) in their efforts to improve access to, and the quality of, health care for over 57 million rural Americans. All 50 states have a SORH, and each SORH helps their state's rural communities to build effective health care delivery systems.

NOSORH has particular concern with issues of rural/urban equity. There are multiple definitions of rural, but under all categorizations there exist multiple disparities between rural and urban communities. These disparities include measures of socioeconomic status, housing adequacy, nutrition, education and health. Rural communities are generally underserved, with significant availability/accessibility issues for health services, human and social services, educational offerings, digital/telecommunication services, food availability and transportation services.

NOSORH's primary concern is in the area of rural/urban health disparities. These include both health status and health service disparities. Exploring the issue of health and health service disparities between rural and urban communities can provide insight into appropriate policy responses for other rural/urban disparities. This review can also suggest approaches to disparities for issues other than health.

NOSORH notes that rural subpopulations are often members of other underserved subpopulations. For example, more than 20% of rural Americans are people of color. Further, in specific regions of the country this percentage is much higher:

http://ruralhome.nonprofitsoapbox.com/storage/research_notes/rrn-race-and-ethnicity-web.pdf

In the rural counties of the South's 'Black Belt,' African Americans comprise a much larger percentage of the total population, including multiple counties where they are a majority of the population. Similarly, in many rural counties of Texas, New Mexico, and California, the Hispanic population is a majority of the total population. Finally, in parts of Arizona, New Mexico, Montana, and the Dakotas, the Native American population is a significant percentage of the overall population. NOSORH believes that policies targeting equity must take into account not just the rural status of populations but also the special needs of racial/ethnic minorities in these communities.

In preparing for its response to this RFI, NOSORH held a listening session on equity for its member SORHs. More than two dozen states participated in this session, providing important perspectives on issues of equity. The comments of SORHs are incorporated into the comments provided below.

Equity Policy Questions:

Issue 1 - Equity Assessments and Strategies: Approaches and methods for holistic and program- or policy-specific assessments of equity for public sector entities, including but not limited to, the development of public policy strategies that advance equity and the use of data to inform equitable public policy strategies.

Comments: NOSORH believes that adequate, regular assessment of key subpopulations is a requirement for evidence-based policy approaches to improving equity. NOSORH feels that this should include both appropriate identification of subpopulation data within existing datasets as well as initiation of new studies targeting key subpopulations. NOSORH has noted that, within the sphere of rural health equity, there are multiple instances where there are no rural-specific data available for either health status measures or health service measures. For example, in its hospital quality measurements, the Centers for Medicare and Medicaid Services (CMS) does not differentiate quality measures in rural versus urban hospitals. NOSORH has conducted supplemental analysis to identify key disparities in these measures, but feels that this assessment should be a responsibility of CMS as part of its approach to equity.

NOSORH recommends that the federal government establish minimum data requirements for all agencies identifying which subpopulations should be identified in their data gathering efforts. These requirements should include, at a minimum, the key subpopulations, including rural populations, identified in E.O. 13985. Subpopulation data breakout should be required at the national, state and local levels. Exemptions for privacy or other reasons should be permitted, but there must be a clear expectation regarding to importance of providing these data.

During the NOSORH listening session several SORHs provided a critique of a number of the subpopulation categories commonly used in policy. For example, the Asian American/Pacific Islander category used in Census data is overly broad - placing in one category individuals from very different cultures with different needs. A similar problem exists for the Hispanic subpopulation category, as well as for the rural category. These classifications do not provide enough definition for equity purposes. Accordingly, NOSORH recommends that the federal government include in its minimum data requirements additional subcategories of populations for a more discrete assessment of equity questions.

NOSORH believes that sporadic, non-comprehensive analysis of data for equity purposes would be an insufficient approach to the improving equity. NOSORH recommends that the federal government conduct regular assessments of disparities and their causes for key subpopulations. These assessments could be conducted by individual agencies or on a multiagency basis. In addition, the assessments could be conducted in collaboration with state governments as is currently done through cooperative agreement for vital statistics and similar data systems. NOSORH recommends that these assessments be included as part of a larger federal equity planning effort, described in greater detail subsequently in these comments.

Issue 2 - Barrier and Burden Reduction: Approaches and methods for assessing and remedying barriers, burden, and inequities in public service delivery and access.

Comments: NOSORH believes that equity, as a public policy target, has inadequately defined targets. Setting measurable equity targets often is not a straightforward decision. For example, during the COVID-19 pandemic there has been significant discussion of racial and ethnic disparities in COVID-19 infection and mortality rates. A simple equity target would be to intervene to eliminate the disparate infection and mortality rates in different subpopulations. This would achieve comparative equity but would miss the point of pandemic response - namely, to reduce avoidable infection and mortality from the disease for all subpopulations. In this case, the target should be to reach a baseline standard equitably for all populations.

The case of rural health equity can provide further insight into this question. NOSORH believes that full health status equity should be an expectation for rural residents. This means comparative equity in life expectancy, premature death indicators, mortality rates, disease/disability rates and maternal/child health indicators for rural and urban populations. In contrast, the question of rural health service equity is more complex.

For certain general health services, such as emergency medical services, it is reasonable to expect equal availability and accessibility to these services for both rural and urban populations. For other services, however, the expectation of equal availability is not reasonable. For example, no one would argue that an isolated frontier hamlet should have its own full-time surgical suite. These specialty services should be accessible through a coordinated system of care within a defined travel time.

Under Public Law 93-641, the National Health Planning and Resources Development Act, an integrated state/federal system was established to define these types of targets for the health system.

https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwjFq6rZ9b3xAhWDm2oFHf_eA0oQFjANegQIDRAD&url=https%3A%2F%2Fstacks.cdc.gov%2Fview%2Fcdc%2F65166%2Fcdc_65166_DS1.pdf%3F&usg=AOvVaw3hZgDMrz8VuOUJBQIOJ_bh

Consensus targets were created in state plans - identifying reasonable availability and accessibility expectations for the health system. Most plans also included health status improvement targets for the general population and for key subpopulations. While this system has since been allowed to sunset, it provides an interesting model for how equity targets could be defined in the future.

NOSORH recommends that the federal government require its agencies to develop an appropriate set of equity targets for their programs. These targets should include outcome measures, performance measures and process measures for key subpopulations. Where appropriate, service availability and accessibility targets should be defined. NOSORH also recommends that, where appropriate, agencies work jointly to establish equity targets.

In addition, NOSORH recommends to the federal government that it require its agencies to develop Federal Agency Equity Plans. These plans should specify each agency's specific long- and short-term efforts to achieve equity targets.

Issue 3 - Procurement and Contracting: Approaches and methods for assessing equity in agency procurement and contracting processes.

Comments: NOSORH believes that changes in agency procurement and contracting processes can improve equitable distribution of federal resources to key subpopulations. The approaches used by federal health programs to assure equitable consideration of rural health needs can provide an example of what could be done for all key subpopulations.

Federal health programs have established four main procurement approaches to assure reasonable consideration of the needs of rural communities:

* Rural Proposal Evaluation Priority: Some programs include extra points in application evaluation scores for projects proposing serving rural and frontier populations. For example, if there are 100 total evaluation points used to score proposals, 10 points of that score might be awarded to rural/frontier applications.

* Separate Award Pools: Some programs 'carve out' available funds specifically for rural applicants. This apportionment assures that rural applicants are competing with other rural applicants and not with better resourced urban applicants. The separate pools can also have different, streamlined application requirements designed to be more appropriate for smaller, rural projects.

* Minimum Award Guarantees: Some programs assure that a minimum percentage of awards or funds are guaranteed to rural projects. For example, a major health center funding program guarantees that at least 40% of the awarded funds will serve rural populations.

* Eligible Applicant Policies: Some programs limit eligibility to applicants located in rural areas. Other programs, similarly, give priority to applicants located in rural areas. These approaches are similar to small business and minority business set-asides used in other federal procurements.

While all of these approaches have limitations, they can be used to improve equity in procurement and contracting. Note that they can be used either separately or in combinations. NOSORH recommends that the federal government direct its agencies to use procurement and contracting procedures of this type to improve equitable allocation of resources.

Issue 4 - Financial Assistance: Approaches and methods for assessing equity in the administration of agency grant programs and other forms of financial assistance.

Comments: NOSORH believes that underserved populations do not have equitable access to enrollment in key programs and that this lack of enrollment access results in reduced participation of underserved populations in financial assistance programs. For example, SORHs have commented that when outreach and enrollment offices in rural communities have closed, participation of rural residents from those communities in Medicaid and other key programs has plummeted.

Some federal programs have addressed this problem through enhanced collaboration with agencies and groups within the target communities. The Patient Navigator initiative, funded by CMS, has funded local groups in rural and minority communities to assist in the enrollment of these communities in health coverage available under the Affordable Care Act. Other programs have adapted enrollment procedures to be more appropriate for underserved communities. Linguistically and culturally appropriate enrollment processes are important approaches to equitable participation in financial assistance programs.

NOSORH recommends that the federal government direct its agencies to conduct targeted outreach to key subpopulations in collaboration with local partner groups and agencies. This could be implemented as part of Federal Agency Equity Plans.

Issue 5 - Stakeholder and Community Engagement: Approaches and methods for accessible and meaningful agency engagement with underserved communities.

NOSORH believes that public agencies should routinely make extra efforts to engage key subpopulations that they serve. These efforts are needed to overcome communication barriers that exist for underserved populations. The model of tribal consultation is a good one to follow. In this initiative, public agencies have regularly scheduled meetings with tribal leaders to communicate program and policy changes and understand the specific needs of native communities. NOSORH feels that this approach can be extended to representatives of other underserved communities.

NOSORH recommends that the federal government direct its agencies to regularly coordinate with national/state associations and groups representing/advocating for the interests of key subpopulations. This coordination should include routine consultations with these representatives. In addition, NOSORH recommends that the federal government direct its agencies to create information dissemination plans to communicate policy and program changes to national, state and local groups representing/advocating for the interest of key subpopulations. It should be noted that SORHS are a federally-recognized focal point for rural health responsible for information dissemination to and technical assistance for the rural health system. State Primary Care Offices, another federally-recognized set of entities, play an analogous role as a focal point for primary care providers throughout the nation. NOSORH believes that the federal government can tap state offices such as these to increase its information dissemination impact.

* * *

The notice can be viewed at: https://www.regulations.gov/document/OMB-2021-0005-0001

TARGETED NEWS SERVICE (founded 2004) features non-partisan 'edited journalism' news briefs and information for news organizations, public policy groups and individuals; as well as 'gathered' public policy information, including news releases, reports, speeches. For more information contact MYRON STRUCK, editor, editor@targetednews.com, Springfield, Virginia; 703/304-1897; https://targetednews.com