Policy Analysis

Nikhil Kalita

PUBH3135W: Health Policy

Dr. Candice Chen

April 25, 2022

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PROBLEM

How can Governor Jim Justice utilize existing health facilities and institutions to improve

access to healthcare in rural communities of West Virginia?

BACKGROUND

Healthcare in West Virginia (WV) is diverse, complicated, and unique as it consists of

many rural communities living in the far reaches of the Appalachian mountains. West Virginia’s

population makes up 1.8 million people, of which 673,000 people live in rural areas (USDA,

2022). Living in rural areas increases the risk of negative health outcomes due to numerous

barriers to healthcare access (RHIhub, 2021). These barriers include long distances to healthcare

facilities, medical workforce shortages, and more (RHIhub, 2021). These barriers may be the

reason why 47% of the rural population have chronic conditions compared to 39% of people in

urban communities of West Virginia (Gupta, 2018).

West Virginia has more than 500 rural health clinics and centers (Gupta, 2018). Yet, these

facilities are not always equipped with a primary care provider on site, decreasing the quality and

access of healthcare (RHIhub, 2021). Physician assistants (PAs) provide high-quality care similar

to physicians (Morgan, 2019). West Virginia is one of 6 states restricting PAs from prescribing

Schedule II medications that are vital for a primary care site to administer (AMA, 2018).

Extensive studies have found that PAs provide cost-effective and safe care, and in some cases,

increase access to rural healthcare with a wider scope of practice (Cawley, 2016).

Non-emergency transportation (NEMT) services are vital in increasing access to

healthcare but are very limited in rural areas. NEMT services are typically provided by Medicaid

systems which most rural residents depend on (KFF, 2018). 35 state Medicaid programs have

implemented rideshare services to provide additional NEMT services that have increased
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cost-efficiency and access to healthcare (Galewitz, 2019). After the Medicaid provider,

CareMore Health, partnered with Lyft, wait times were reduced by 30% and the cost per ride

decreased by 32%, saving more than $1 million in one year (Farr, 2017). However, one study

found that Medicaid patients missed the same amount of doctor appointments with ride-sharing

programs as without them (Chaiyachati, 2018).

Healthcare workforce shortages in West Virginia have been partly caused by the fact that

only 10.2% of West Virginian medical students eventually practice in rural West Virginia

(Walker, 2009). The strongest predictor of rural practice choice is students having a rural

upbringing or background (Brooks, 2002; Hancock, 2009). Additionally, physicians who receive

part of their residency training in rural areas tend to stay longer in rural practice (AAFP, 2019).

Many rural-practice incentives are offered by the West Virginia University (WVU) Medical

School (like full in-state scholarships of $28,000), but none target students specifically from

rural areas (WVU, 2021). One program that targets rural-based students is the Rural Health

Program at Kansas University with the eligibility requirement of “significant experience living in

a rural community” (KU, 2022). The program provides a pipeline to a loan repayment program

for those who work in underserved areas (KU, 2022). Many physicians from this program

eventually practiced in rural counties in Kansas, most likely due to their rural upbringing and the

increased effectiveness of loan repayment programs (Weber, 2019).

LANDSCAPE

Many strategies to combat rural healthcare issues have been endorsed and implemented

by Governor Jim Justice (R) of West Virginia (Gupta, 2018). In April 2021, Governor Justice

signed scope of practice Senate Bill 714 which allowed for PAs and physicians to interact via

telecommunication instead of requiring physicians’ physical presence on-site (WV Legistlature,

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2021; Takubo, 2021). In the Rural Health Plan 2018-2022, supported by Governor Justice, the

importance of offering more sustainable NEMT services is significantly highlighted (Gupta,

2018). Governor Justice has also worked to retain non-physician providers through grant funding

for West Virginian healthcare education programs (Damron, 2021). Due to Governor Justice’s

recent efforts, he would be supportive of all policies aimed to expand PA scope of practice,

NEMT services, and incentives for West Virginian health professional students.

Governor Justice and the WV State Legislature are more likely to favor policy options

that are less costly to the state government. This is because Republican legislatures are typically

less supportive of increased government spending. Additionally, about 80% of all federal funds

that West Virginia receives are for Medicaid (KFF, 2018). So, any policy option that saves

Medicaid costs will be preferred by the WV State Legislature. The WV State Legislature also

signed the scope of practice expansion of advance practice registered nurses in House Bill 4111

(AFP, 2022). Therefore, they would likely support another useful scope of practice expansion.

However, the American Medical Association (AMA) has found that quality and patient

safety has been compromised when oversight is reduced (AMA, 2021). They have combated

scope of practice expansions through letters to state governing bodies, court representation

against independent practice bills, and more (AMA, 2021). AMA is bound to oppose a policy

proposing a reduction in the level of medical oversight.

The West Virginia University (WVU) school of medicine has developed a Rural Track

Program to increase the retention of medical students for in-state residency programs. Funded by

the state, WVU offers $1,000 stipends to medical students participating in rural shadowing

experiences (WVU, 2021). WVU would be supportive and a key player in implementing

programs that provide effective, evidence-based rural practice incentives for their students.
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POLICY OPTIONS
Option 1: Expanding PA Scope of Practice

With frequent workforce shortages and rural health clinics providing lower-quality care,

expanding the scope of practice of physician assistants (PAs) is a viable option to increase access

to quality healthcare. Specifically, PAs should be permitted to prescribe Schedule II medication

themselves, without requiring a physician to be present on site.

PAs are effective in providing the same quality primary care as physicians. PA

expansions have also somewhat increased financial efficiency and access to rural healthcare. The

cost of implementing this state legislature would be about $1,000 from legislation fees and an

additional $3,000 from salary expenses. Governor Justice and the WV State Legislature would

be supportive of this option based on their prior actions and the option’s low cost. But because

the AMA has been consistently fighting scope of practice expansions in many states, this policy

option is not as politically feasible.

Option 2: Ride-sharing NEMT Services through Medicaid

Medicaid-sponsored ride-share services can meet the demand for additional NEMT

providers to increase access to healthcare transportation in rural areas. Through an electronic

health record, physicians can order a Lyft or Uber driver to pick up a Medicaid patient.

Medicaid programs can save money as spending on NEMT services would decrease by

32% from partnering with a ride-sharing company. This would significantly reduce state

government spending on Medicaid. Because this policy option would save costs, it is more

politically feasible and appealing to Governor Justice and the West Virginia State Legislature.

Governor Justice would also support this option as he has voiced his concern about limited

NEMT services. Its effectiveness may be low because it barely reduced missed appointments

among Medicaid patients in other areas.

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Option 3: Loan-repayment Programs for Rural-Based Medical Students

Providing tailored incentives for 7 rural-based, in-state medical students who are a part of

the WVU Rural Track Program can increase the healthcare workforce in West Virginia. Through

the collaboration with the WVU Medical School, $28,000 (the price of in-state tuition at the

WVU Medical School) loan repayments should be offered to candidates each year after they

graduate and are actively practicing medicine in rural areas.

This option can be very effective because it targets students with a rural upbringing,

incentivizes students to stay in rural residency programs, and offers loan repayments which are

all found to be indicators of retaining medical students in rural medicine and practice. With 7

WVU candidates accepted every year, a maximum of 28 providers will receive $28,000 in loan

repayment each year, potentially costing the state and WVU $784,000. Although Governor

Justice and the West Virginia Legislature have recently provided monetary support for health

professional schools, the high cost of this option makes it less politically feasible.

POLICY ANALYSIS

Out of the 3 policy options listed, the use of loan-repayment programs for students of the

WVU School of Medicine Rural Track Program, is the recommended policy choice. Although it

is the most costly, and not the most politically feasible, its effectiveness greatly outweighs that of

the other policy options. The effectiveness of Option 1 is mediocre because there is no evidence

indicating a significant increase in rural access to healthcare with an expanded PA scope of

practice. The effectiveness of Option 2 is low because rideshare programs have not yet proved to

reduce patient missed appointments. Option 3 is based on quality evidence that ensures that most

primary care physicians of this program would practice in rural communities, increasing access

to rural healthcare in West Virginia.

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Option 1: Option 2: Option 3:

Expanding PA Ride-sharing NEMT Loan-repayment
Scope of Practice Services through Programs for
Medicaid Rural-Based
Medical Students

Cost Medium Low High

Political Feasibility Medium High Medium

Effectiveness Medium Low High

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