Federal Healthcare Policy & Legislation Updates with Alexa McKinley-Abel

Jeremiah Hodshire (Host): I am excited to be in the studio with today’s special guest, and I’m always excited whenever I can bring someone from the National Rural Health Association onto our podcast, because the conversation is always natural. It’s organic in nature, it’s fun, and it is always informative. After almost every podcast with an NRHA guest, we always end up with a tremendous amount of engagement from our listeners because there’s a lot of issues and that the NRHA is addressing and dealing with on a daily basis. So, it’s great to have today’s special guest, Alexa McKinley Abel, who is a government affairs and policy director at the National Rural Health Association known as NRHA, a good friend of ours. And so, for our listeners, across the country listening, who may not know you, I know you’ve done some webinars and you’ve been on a lot of our calls from the grassroots advocacy level. But tell us about your role at the NHRA. How long have you been there? What brought you to the organization and why in the world, in today’s environment, did you choose this job?

Alexa McKinley-Abel (Guest): Great questions and thank you for having me. So, I am on NRHA’s Government affairs team, which you could probably guess from my title. And I lead both our work on the Hill, so our legislative advocacy as well as our work with the executive branch. So, reading regulations, meeting with CMS, all that fun kind of stuff. And how did I get here? I wish the story was a bit better, but I went to law school and I realized I wanted to work in policy rather than in a law firm. So, I moved to D.C., I got this job, and I actually had no health policy background, but I’ve really found a passion and a love for health policy. And of course, in particular rural health. It’s like one big family here at NHRA and among all of our members.

JH: So, Alexa, tell us, where is NRHA headquarters today?

AMA: So, I’m in D.C., but we are technically headquartered around Kansas City. So, my team is in D.C., which makes sense to do the advocacy. We have a lot of folks out in the Kansas City area as well.

JH: When we toured several years ago with some consultants that we were working with, we had a chance to go to NRHA, meet with your director, had some great conversations about, rural healthcare in Michigan and then a greater audience as we launched our podcast. But it’s great to have you, Alexa, here for our listeners who may be listening in Texas, Arizona, Alabama, they may have no idea who you are. Why don’t you tell us a fun fact about yourself to humanize you a little bit to this podcast?

AMA: Well, I don’t know how fun it is, but I have to say this because you’re in Michigan. I’m a michigander. I was born and raised in Michigan. In Clarkston, Michigan. And I went to Michigan State.

JH: So, you grew up in Michigan. So, you know, the challenging winters we have and but the beautiful summers.

I miss it so much. I usually come back when Congress is in August recess and spend the summer with my family. So, it’s really nice that I’m able to do that.

JH: Do you have any favorite spots in Michigan for summer, like vacation areas?

AMA: I love Saugatuck. Oh Lake Michigan.

JH: Our children lived in Holland for a while, and we just loved going to the Tulip Festival and just great, great, beautiful landscape in Michigan, that’s for sure. Well, that is a fun fact. It’s great to have another Michigander on the program. Well, let’s jump right into this. I want our listeners to know that today we’re talking about the impact of funding cuts and very harmful legislation on rural communities and hospitals. And unfortunately, right now, the talking points in Congress are that the one big beautiful bill isn’t as bad as we say it is. They say that the rural health transformation funding is going to make it all better, which we know it’s not. And we’re faced with some paramount decisions to make as rural hospitals. So, Alexa is here to share her perspective as an expert in government policy and advocacy about the things that we can do. We’re going to talk about the role of state offices, the newest budget cuts proposed for fiscal year 27, and, of course, what all of this has to do with rural health.

JH: Let’s jump into, you know, some meat here of the issue. The president of the United States, Donald Trump, has released his proposed fiscal year 27 budget, and this is what he would propose. So I guess you’ve had a chance to look at it. It takes a lot to dive into it. Of course, I fully understand that because it’s there’s so many nuances. There’s no expert on it yet. But from what you’ve reviewed, how does it impact affordability from your perspective? And looking at the total proposed budget, how would that impact hospitals, rural hospitals specifically?

AMA: Great questions. Before I dive into that, I think the key point you made there was proposed budget. So, there’s, you know, there’s a little good and bad on this. This is a signal from the administration in the white House as to what they would like to see Congress pass in the fiscal year 2027 appropriations process. The good news is Congress does not have to listen. And in fact, last year we saw a pretty similar budget. And they didn’t. They actually gave rural health programs increases. So, a little glimmer of hope there. But in terms of what the budget looks like this year. How could it impact affordability and hospitals? I think those kind of go hand in hand. So, there were proposals to cut funding for hospital programs and hospital adjacent programs, I would say at the Federal Office of Rural Health Policy. So that includes the Medicare Rural Hospital Flexibility Program and Small Hospital Improvement Program, the state Offices of Rural Health Program, the Rural Hospital Stabilization Pilot, and a new program, the Rural Hospital Provider Assistance Program. So, a lot of hospital terms in there; FLEX, SHIP, the rural hospital stabilization and the provider assistance programs directly impact hospitals. FLEX and SHIP, I’m sure you and many of our listeners are familiar with gives funding directly to those hospitals. If that was eliminated or given $0 in the FY 27 process appropriations process, your critical access hospitals and small rural hospitals would not be receiving that money to do the work that they do with those grants. Without the state offices of rural health, there’s not going to be that kind of level of coordination across rural health systems in the state. So big impacts for rural hospitals should this budget be adopted by Congress.

JH: So, Alexa, let’s dive in a little bit here because I’m going to go back to your original statement that, you know, there’s hope because, you know, the Congress last year said, well, we’re going to prioritize some real health. Does the makeup of Congress look about the same that it did last year in terms of party?

AMA: Yes.

JH: So, all things equal, there could be some positive if but Alexa, how do we get to that positive point. And I mean it’s not just going to happen organically. It usually takes hospitals associations lobbying. What advice would you give to the CEO listening today who’s really concerned about the president’s budget? What action can they take?

AMA: Get in touch with your members of Congress, particularly if they sit on the Appropriations Committee, which you can look that up online, just telling them how important these programs are to your hospital goes a lot further than, me coming in and saying that because I’m not running the hospital in their district or in their state. So, this doesn’t have to be a meeting. You don’t have to come to D.C., you can send them an email, you can call their office, you can set up a virtual meeting. They are actually all at home right now too. So, when they’re back in the district or in the state during recesses, you can meet with them there or meet with their state staff. So, plenty of ways to engage. But just telling your story of how, for example, flex funding is used at your hospital and how integral it goes a long way.

JH: Yeah, and it’s critical that you tell them, like, I can tell my elected official today what exactly the SHIP funding.

AMA: Exactly.

JH: And I think those are important conversations to have. So, as you begin to unpack fiscal 27, can you give us a timeline of what happens next? Like, you know, is all hope lost with the Medicaid? We’re going to talk about that in a minute. But I mean, what happens next? Congress will get back together. Will we see any reconciliation? What are you thinking?

AMA: So right now, is an interesting time because the appropriations process is happening, which we were just talking about. And there’s going to be the different appropriations bills released and then marked up, which just means debated within the Appropriations Committee and then theoretically passed. And fiscal year 26 ends at the end of September. So, they need to have a 27 appropriations package passed by that time. We know that never happens. We typically get stuck in a continuing resolution, and they may or may not pass a full appropriations bill after that. And then there’s also talks about reconciliation. So, the reconciliation that’s been happening recently was really around funding the Department of Homeland Security and debates there. So outside of the healthcare space, however, we are hearing chatter about reconciliation 3.0. So that’s another very partizan and busy process that Congress could be undertaking this summer, and that I think the focus would likely be on Medicaid again and really honing in on waste, fraud and abuse, which has been a huge talking point both on the Hill and from the white House. So, we don’t have exact proposals yet. We don’t know what it would look like, but that is my sense of where the focus would be.

JH: And this is a time in the districts where, you know, congressional leaders are off, that your constituents should be reaching out to them, having those meaningful dialogs about, let’s get this passed, let’s prioritize. Okay, so let’s dive into a couple other areas. So, it’s a concern. We’ve established the president’s budget. There’s a lot to unpack. But there is hope that Congress can reprioritize rural health. And we speak to rule health specifically because it’s what I do every day and it’s what you’re engaged in. So, we know what happens when rural hospitals close. Not only are we the economic engines for those communities the community suffer, but also healthcare outcomes are far worse. Individuals end up traveling farther distances to get the care that they deserve and that they need. So, we’re trying to preserve it. But today, Alexa, across the country, we’re talking about hospitals that are closing at record pace. Scott Becker a oftentimes on this podcast, he, him and his team do a lot of research. They do a lot of work. They produce a lot of reports that site other studies that have been done. And right now, we know 734 hospitals in this country are at risk of closure. Half of those are at an immediate risk of closure. 20 of those hospitals have identified at risk of closure in Michigan, and six at immediate risk of closure in Michigan. Very, very serious situation. So, I guess in light of all of that, the tumultuous times that we’re facing, payer negotiations you’re talking about, obviously labor costs are up. It’s difficult to find labor. You’ve got supply chain cost increasing. You’ve got tariffs. Wow. The perfect storm in this country. At the same time government is cutting programs.

JH: what do state offices of Rural Health provide to communities and hospitals in particular for weathering such storms as this? And what would the loss of programs such as the Medicare rural, FLEX Program, Stabilization Program, Provider Assistance Program do? In your estimation of studies that you’ve done of hospital closures, what would those do to communities?

AMA: So, with the State Offices of Rural Health Program for the audience, the state offices are really the focal point for rural health in their state. They do so much in terms of coordination and knowing intimately all of the rural hospitals and clinics and providers in the state. And not only that, they administer the FLEX and SHIP programs. So, you know, they’re trusted partners in that way. And they make sure that FLEX and SHIP aren’t just administered, but those are truly impactful programs, and the money goes the furthest that it can go at these hospitals. And then again, they have those long-term relationships with hospitals and other healthcare providers in the state that allows them to do that. As the name suggests, state offices. It’s a federal state partnership with a 3 to 1 match requirement. So, every federal dollar that’s invested, the states contribute $3. It’s very economical. It ensures that there’s, you know, responsibility shared among the states and federal government. It maximizes the impact of federal funds. And in Michigan, there’s a 27-fold return on investment from federal funding that’s invested into the state offices program. So, they are really just the backbone of rural health. And if that was pulled out from under a state, there would be nowhere for many providers to go. There would be less technical assistance and education provided or training provided. The FLEX and SHIP programs wouldn’t be able to run. So, they’re so important in the rural healthcare system.

JH: So, Alexa, would there be a possibility for if Congress withdraws the funding, can the state reserve the right to backfill that funding if, I mean, obviously, if they have the funding? Or is this a national office that’s established at each state?

That’s a good question. I would say that it’s a federal program, of course, run through the federal government, but I’m sure that a state would be able to if they had the funds injected into there and hopefully keep it running to some extent. It would not look the same as it does now, I don’t believe. I think that would be a possibility, although state budgets are so stretched.

JH: Oh, my goodness. Yeah. Tell me a state budget that’s not stretched. Yeah. Especially in light of what we’re going to talk about next. But before I do that. Do you work with the state associations at all in the capacity of the NRHA?

AMA: Yeah, we work with the state offices of Rural Health, and we also work with the National Organization of State Offices of Rural Health. So, believe they’re all our members. We work with them like last year and this year, as you know, their funding line was proposed to be eliminated. We helped them to understand how they can advocate within their roles and help protect their funding. They’re really close partners of ours.

JH: You know, Alexa, let’s talk a little bit about advocacy. Do you find value in, our listeners or always trying to balance us, should I leave my organization for two days of traveler three to go to Washington several times a year, and we’ve had mixed reviews. We had a gentleman I just interviewed in the podcast that said, he goes out once every two months. He makes it a point. You know, I’ve had other leaders that said, JJ, we can’t even get away from our current, you know, jobs and what we’re trying to do. What is, I guess, the sweet spot for that. Where would you find the best opportunity for a hospital CEO or CEO or administrator? Should they be in Washington? Is that something that you feel is necessary?

AMA: So, I think to the extent that the organization can provide the funding and availability, the gold standard is really an in-person meeting, but I don’t want to diminish other forms of advocacy or virtual meetings or letter writing, whatever it might be. But going in and meeting with your members of Congress face to face is truly kind of an irreplaceable experience, and it helps them probably remember you a bit more. So, you know, if you want to have their phone number and your phone, I would probably suggest going and having in-person meetings with your member when you can.

JH: And you provide any resources at the NRHA for advocacy?

AMA: Yes.

JH: Okay. And so that would be found on your website if individuals want to look there.

AMA: Yes. And if you’re an NRHA member, we can help you schedule those meetings too. We’re happy to do that. We can come to them with you if that makes someone more comfortable. If not, we have so many leave behind materials that you can print and bring or send as follow up. We’re really here to help you and ensure that your advocacy is as successful as it can be.

JH: Fantastic. All right, Alexa, let’s blow up this podcast because what we’re going to talk about is heavy on the minds of every hospital administrator in this country that works in a rural setting. I know that because we speak to them all the time. I just came back from Becker’s, where I spoke. Hundreds and hundreds of leaders are very, very concerned about the passage of H.R.1 and the impact that that will have with the reduction of Medicaid reimbursement to states. Now, many people and we’ve tried to do it on this podcast. Many people don’t understand the complexity of why the federal government would give money to the states for a state-run Medicaid program. Let’s just start there. Can you can you tell us how do you think the current political landscape today is impacting the new proposals? And what I want to tell you is that I had dinner with Rick Pollack several months ago, American Hospital Association president, and he was in Lansing. He was at one of our MHA hospital board meetings. And Rick made a very interesting comment. Rick’s been there for 40 some years. He said, it’s highly transactional right now. And as I talked to leaders and to and to advocates and I talked to lobbyists, they tell me that they’ve never seen such an environment as it is today, where it’s almost 100% business transactional. We’ve kind of taken out that human element of concern and care. And I added those words myself. Rick Pollack didn’t say that. I’m saying we’ve taken out some of the human element of that. So, let’s talk about the political landscape and these new proposals, specifically as we look at the cuts to healthcare that are coming that we know are coming. We have congressmen and women that are out there lying, and I will call it, you don’t even have to comment on that comment. But they are telling people that there’s no cuts. There are no cuts to healthcare. It’s all smoke and mirrors. We’re getting rid of the waste, the fraud, the abuse. They shouldn’t be worried about that. They should be focused on this. They shouldn’t be building all their buildings. Or executives make too much money. They flip the narrative. And what they do is they spin doctor it, and they’ve been successful at doing that. And by and large, this is my party that’s doing it today. And they are going out and saying that even with those cuts that are coming, they’re going to be fine because we gave them $50 billion. You know, we cut 1 trillion. But by the way, we gave back 50 billion. And that program itself is something that congressional leaders are going out saying are going to save real hospitals. In fact, there’s been leading research articles that have just been produced that that have actually articulated that hospitals actually could face faster closure from this. So, let’s talk about the political landscape, and let’s talk about how it’s impacting under H.R.1. What does it look like in the landscape for these cuts?

AMA: Well, I think you hit the nail on the head in terms of the current political landscape. And to make things even more complicated, it’s a midterm election year this year. So probably within the next month or so, any bipartisan work will become extremely difficult, if not impossible, and nothing will happen except maybe a reconciliation package, because that does not require bipartisanship. So, until the elections are over, we are in a super, super partizan DC environment. You know, maybe after the elections there could be an opportunity for a lame duck package, depending on how the elections shake out, where, you know, people may come together and try to pass some legacy bills for those that are leaving Congress or just come together and pass one last thing to show that they did some work, but otherwise the next several months are going to be very, very difficult and make an already bad situation kind of worse. And then when we’re thinking about, how is this going to impact healthcare and the rhetoric around H.R.1 and the Rural Health transformation program, again, you hit it. There’s a belief that RHTP will kind of save rural healthcare. But we know that there is a huge disparity in the 50 billion invested versus how much rural communities stand to lose in decreased Medicaid reimbursement. I believe it’s the Kaiser Family Foundation that estimates 135 billion in decreased Medicaid payments to rural areas as a result of H.R.1. So, you can do the math there. Billion invested 135 billion removed. It’s not going to make up for that. It’s a great investment, like don’t get me wrong, but when you are making people lose Medicaid coverage and changing the financing systems and how money flows from Medicaid to rural hospitals, RHTP is not going to fix that or keep those doors open.

JH: Absolutely. It’s not going to. And when we face the challenges of now shifting that burden to the state, let’s talk about Michigan, which I can speak about. Michigan doesn’t have the budget to assume the difference between the two. And so, the states now are faced with significant challenges. But let’s talk about what actually could happen, because this actually goes through 2032. Some of the provisions don’t start until 27. We know that. Incremental through 27 to 32, but midterms could impact it. When you’ve looked at midterms before in the past. How long does it normally take, though, for legislation to get derailed that the that maybe another party is proposed. I mean it’s not going to be overnight.

AMA: No. And it would really depend on the outcome of the elections. Right. So if we’re thinking about how can we undo H.R.1, that’s impossible in the current situation, right, where we have Republican led Senate, House and white House, and even in a world where Democrats would take over both chambers of Congress, it’s extremely unlikely that they could undo much of H.R.1, because the president signs every bill that passes Congress. So, it’s not something that could happen soon. And that’s why we, like I said earlier, our tracking on what CMS is doing to implement these provisions and trying to work with them to make it as least harmful to rural health as possible within the bounds of the statute, because they are limited by that.

JH: And what we anticipate with these closures of hospitals, let’s talk about let’s just move beyond the economic impact to the community. Healthcare outcomes are what we’re talking about.

AMA: When there’s a hospital, clinic, whatever it may be that closes and there’s less access to preventive care, primary care, we know health outcomes go down. And we already see that rural health outcomes lag behind urban outcomes. So, this will only make the situation worse when we see H.R.1 related hospital and clinic closures, because there’s going to be less access to care.

JH: And then what we’re finding now with some of the challenges that have already occurred with the population, specific to the tax credits that are no longer available on the marketplace, is that we’re watching a population of individuals who are either shifting to no pay. Bad debt, no pay. Slow pay, we call it. Maybe they’re making $20 payments and its crippling hospitals to the point where several of my peers are talking about closing essential services. And, Alexa, you know better than anyone the two services that impact the community most that are the first to close obstetrical care and psychiatric care. And we’re starting to see that across the country. And that’s alarming. Do you want to weigh in before we close today on, you know, the clinical impact of these decisions?

AMA: And I’m glad you brought up the ACA tax credits because I think those expired, people moved on. But we are seeing more uninsured, more people fall off the marketplaces or enroll in plans that pretty much underinsured them. Or like those bronze plans, don’t have as generous of coverage as some of the more expensive plans. So that’s happening in real time. And like you said, some of the Medicaid changes. So, things like work requirements that will get people off of the Medicaid rolls won’t go into effect until 2027. So, then we’ll see another wave of individuals losing coverage. And to your point, that is not just going to impact health outcomes, but it’s going to impact the actual facilities that maybe they don’t close their doors right away, but they stop providing behavioral healthcare. There’s no longer maternal healthcare, and someone has to travel an hour instead of 20 minutes. So, there will be impacts on those health outcomes that we continue to see down the road. It’s going to be a slower burn of those things happening because of the way that some of the provisions were spaced out in H.R.1.

JH: So, you heard it today. Alexa has made it very clear that the only way to reverse course is to let your voice be heard. If your congressional leader is not hearing from their constituents that this is a problem, they’re going to assume business as usual, and you have got to lift your voice. Now, there’s several ways you can do it. First of all, we always say we have to do it responsibly and in order. Even though today’s politics is all about yelling, screaming, name calling, we have to rise above that. We have to be respectful. We have to do this with civility and have meaningful conversations about how to change the course of some of the decisions that have been made. So, you do it by reaching out yourself. If you don’t have a relationship with your congressional leader or state leaders you need to do that immediately as an executive. Schedule a visit. We find Alexa that these are very meaningful to have congressional or state leaders walk through your facility. They see the faces that are not waste, fraud and abuse. They see the people voting for them like pastors in my community. One of them that I know is on Medicaid. That’s not waste, fraud and abuse. And so, they’ve got to see those faces. I think that’s important. Third, rely on an association like NRHA because they can become your advocate when you can’t get to Washington. And they will lift up their voice, which lifts all of our voices up. But if you can give the NRHA, if you’re a member, a specific stat, specific stories, they want to share those with your congressional leaders. So, we would encourage you to go to the show notes. Talk to your leader. If you’re the leader, make a decision to prioritize a membership with NRHA. We feel that that is so critically important. We just did that all in about 38 minutes. We have a few minutes left to talk about. Some, you know, in today’s climates, tumultuous. We’ve already established that, it’s brutal. It’s ugly if you speak out, you know, in for a specific cause like Medicaid, you get branded, you get yelled at, you get name calling. You know, never in our history have I ever witnessed at this level. And so, it’s a lot of pressure on new leaders, especially in healthcare. And that’s what I want to focus on.

JH: So, Alexa, you’ve been in the business. You’ve been around a lot of state associations, a lot of leaders throughout the country. If we have a new listener today who is brand new to their position in leadership, what sage advice or what piece of information wisdom would you give them in in the fight that we have ahead of us right now?

AMA: So, I think this whole episode really teed me up for my answer for this. And my answer is get involved in advocacy. And like I said, you can dip your toes in and it doesn’t have to be coming to DC for a meeting. We have advocacy campaigns where all you do is literally put in your zip code. There’s a pre-written message, and it is sent to your members of Congress office if you want to get to know them that’s also great, because being a trusted partner to a member of Congress is really great. They may turn to you specifically for questions about rural health or your hospital, and rely on you for that kind of information. And just generally, I can’t do what I do without you all. So, constituents are incredibly important resources. Your stories are incredibly important to us because we’re able to share them. I’m able to give data or anecdotes or examples. So, I would just say get involved in advocacy in the way that you feel comfortable, especially in today’s day and age. And yes, while things seem crazy, overall, if you meet with a staff member or a member of Congress, it’s going to be a great meeting. You’re going to be feeling fulfilled. They’re kind. They really do genuinely care for the most part. So, while the whole world may seem crazy and scary and you don’t want to speak out, your member is. Their job is to listen to you. I highly encourage you to get involved in some way. And like I said, we have lots of resources to make that easy.

JH: Well, it’s been great to have you on the program here today, Alexa, and I look forward to maybe in a few months. Have you back on to give us an update on what actually happened in three of that and advocacy, and I’m hoping we have a victory for rural health. I know we’re all pushing for it. Our listeners that listen in are pushing for it. So, thank you for your time today. It’s always insightful. It’s always great to have leaders from NRHA on this podcast to share your wisdom and information with the rest of the country. So, thank you for your commitment.

AMA: Thank you for having me. It was a pleasure.