The state of rural health care has long been a popular topic for lawmakers seeking to get elected or pass legislation once in office. Both quality and quantity of care in these geographical areas could inarguably improve, so activists across the political spectrum seize on the issue as a talking point.
Certificate of need (CON) laws, which the federal government essentially mandated 50 years ago as one proposed solution to the problem, remain hotly debated today. These laws require anyone trying to create or expand a medical facility to prove their services are needed in the area they want to practice. (The convoluted rationale behind this claim would not fit in this blog post, but Investopedia provides a concise summary.)
Although the federal government repealed its mandate almost 40 years ago, and both it and the American Medical Association (AMA)—initial supporters of the idea—admitted the laws failed to achieve their goals, only 15 states have abolished their CON programs.
Lobbyists still claim CON laws help rural Americans access better health care, and well-meaning legislators and voters still believe it. But a few simple facts clearly illustrate the counterproductive nature of these laws.
They have not improved rural access.
Not only do states maintaining CON programs have 30% fewer hospitals per capita overall, they have 30% fewer rural hospitals. They also have 14% fewer ambulatory surgical centers (ASCs) per capita. Correlation does not always equal causation, but the results of 40 years of varying CON laws throughout 50 states offer some compelling evidence. The laws have either contributed directly to poor healthcare access or, at best, failed spectacularly to fix it. And logic bears this out, as refusing to allow someone to open a new hospital or ASC is obviously not going to result in more of them.
Monty Veazey, president and CEO of the Georgia Alliance of Community Hospitals, recently argued that Georgia needed to keep its restrictive CON program in place to protect rural access. However, eight rural hospitals have closed in Georgia in the last decade, and 19—more than a quarter of the state’s rural hospitals—are at risk of closing, according to the Center for Healthcare Quality and Payment Reform. But Georgia has the seventh-highest number of CON restrictions in the country. Again, either the laws have contributed to the problem, or they have failed to remedy it.
CON laws do not include quality control.
Veazey also claimed the CON program is important because “it has quality control rules and regulations.” He did not specify what these were, but it is vitally important that voters and legislators understand this claim is false by definition.
CON laws, by definition, simply require proof of need. Saying otherwise misleads anyone rightfully concerned about the safety of medical facilities. To do so implies that CON itself is protecting them from unlicensed providers or subpar services. In reality, anyone wishing to improve quality must implement regulations directed at quality.
Healthcare legislation cannot morally or logically be justified on economic grounds.
Business owners and employees naturally want laws beneficial to their jobs. However, enacting medical care legislation based on how it will enhance one company’s profits is dangerous and irresponsible. Healthcare laws are supposed to enhance health care, not to protect business investments.
Although everyone likes to see local residents maintain their steady jobs, everyone loses when legislation designed to govern medical services aims instead to stimulate a local economy. Just as anyone wishing to enhance safety needs to focus on safety regulations, anyone wishing to address economic concerns needs to focus on economic policy.
Unfortunately, economic interests often do dominate the conversation around rural health care. The Western Journal of Medicine emphasizes that “rural hospitals make an important contribution to rural economies.” Veazy worries that a community hospital closure “causes other businesses in a small town to close.” These concerns may be valid, but again, healthcare policy does not exist to protect the local car wash and hamburger stand.
Furthermore, even if a new medical provider harms the business of an existing practice, it obviously creates jobs at the new facility. Some growing pains may result as jobs move from the current hospital to the new one or to an ASC, especially if it is a town away. But more competition is good for the overall economy, with both patients and workers benefiting from increased options.
CON supporters are CON beneficiaries.
Finally—and perhaps most importantly—those trying to maintain CON laws tend to be established hospitals with a vested interest in preventing new facilities from opening and competing.
Veazy, as noted, heads a community hospital organization. He laments the possibility of ASCs “drawing the paying patient out of the hospital.” This would indeed affect his bottom line, but surely medical legislation does not exist to raise his bottom line. Patients, voters, and legislators have the right to choose their own providers and not have one forced on them.
And Veazy is the norm, not the exception. In Florida, 20,000 petitioners requested that a new hospital open to serve the growing city of North Port. The state initially approved the project, but other hospitals appealed and won. North Port patients lost.
In Virginia, numerous residents showed up to a community meeting to request a new neonatal unit receive permission to be built. The only opposition came from Alice Ackerman, a professor of pediatrics at the Carilion School of Medicine, which is linked to Carilion Hospital. Again, the established hospital won, and the patients lost (with tragic consequences, in this case).
Good intentions do not equal good outcomes.
By no means do all people singing the praises of CON laws harbor ill intent. Community hospital leaders may well believe they provide superior medical care to ASCs. They may well care about the jobs of their members and residents of their communities. But the facts speak for themselves, and the biases of existing medical providers, however understandable, can no longer take healthcare decisions out of the hands of patients.