In the lead-up to the 2020 presidential election, America is coming to terms with a grim reality: thanks in large part to the federal government’s destructive, centrally planned healthcare initiatives, the healthcare industry is deteriorating rapidly. The system doesn’t have the resources to address the United States’ growing medical needs -- and nowhere is this more acutely felt than in rural America. 

A December Fox News report highlighted how fixing the rural healthcare crisis has become a top campaign issue for many states. Since 2005, over 160 rural hospitals have closed their doors, and no less than 430 more are at risk of shutting down. Coupled with the looming doctor shortage, the shuttering of rural-based hospitals presents a difficult problem for the 46 million Americans living in low-population-density areas.  
 
President Trump has been ahead of the curve on this issue. His office isn’t merely parading slogans and empty promises; for the last three years and counting, it has been working to combat this issue. Whether the administration is updating Medicare payment policies to advance rural medical innovation or easing regulations for rural providers, it has done a great deal to expand healthcare access throughout the American heartland. The residents of critical electoral states like Iowa, Pennsylvania, and Texas have taken note. 

The Democrat nominees have taken note as well. In an attempt to cut into the president’s rural voting base, candidates such as Pete Buttigieg and Amy Klobuchar have drummed up some noise by trotting out their own “solutions” to this crisis.  
 
Their pie-in-the-sky plans won’t mean much to these voters -- not when they already have a proven ally in the White House. However, if the Trump White House makes any mistakes on this issue, it will allow them to pounce and steal away some support. And unfortunately, if implemented, a well-intentioned but harmful new measure from Trump’s Center for Medicaid and Medicare Services (CMS) can do just that. 

CMS recently proposed policy, called the Medical Fiscal Accountability Regulation (MFAR), intended to reform Medicaid. At issue are the federal matching funds Washington, D.C. provides to the states for the entitlement program -- a policy that has unintentionally led to the states ballooning their Medicaid budgets, thereby costing the federal government a considerable amount of money. 

The intuitive solution, it would seem, would be to get rid of this matching fund setup and instead impose a reasonable annual cap on what the federal government disburses to support each states’ program. But MFAR -- the Trump CMS plan -- will instead enact new mandates on how the states can fund Medicaid. While the objective appears to be to reduce the matching funds that Washington is on the hook for, it will also inadvertently tie the states' hands, preventing many of them from keeping their already underfunded hospitals afloat. 

The Texas Organization of Rural & Community Hospitals put it best:  “The rule summary notes a goal to 'promote transparency,' which we support, but the remaining ~200 pages are very problematic for rural healthcare... and state flexibility authorized by the Social Security Act.” 

Indeed: MFAR would change the rules to restrict the states from using any public funds to finance Medicaid, as the law currently stands, and instead only allow them to use local taxes, state taxes, or state university teaching-hospital budgets. This plan, however, ignores the ways that many rural states fund the program. Many use patient revenues and other intergovernmental transfers, which will now be forbidden. This prohibition will threaten rural hospital reimbursements despite their already razor-thin bottom lines. 

Top-down solutions like MFAR aren’t the answer. As Allan Morgan, the CEO of the National Rural Health Insurance Association, stated, “Each rural community is unique, and what they need from a health care standpoint, is unique as well, so any federal proposals have to be flexible in nature and recognize the diversity which is rural America.” 

While the federal government can and should prevent manipulation of the program, violating states’ rates is not the best avenue to do so. Since the federal Medicaid match is the only reason that the state budgets concern the federal government in the first place, it can rectify this issue by tackling that head-on and replacing it with an annual cap. Instead, it’s trying to set one-sized-fits-all rules that will backfire. 

MFAR will lead to state budget problems, causing more vulnerable hospitals closing their doors and the access to care problem across rural America to spiral out of control. And at this time, with Mayor Buttigieg and Senator Klobuchar trying to find any screwup that would allow them to weasel into the president’s base of rural support, that’s something that the Trump administration can’t afford to have happen. 

Benjamin Alli, M.D., Ph.D., is a Sakellarides professor of medicine and surgery and the chancellor of the Royal College of Physicians and Surgeons of the United States of America.