HA545 Unit 9 Rural Residency Advocacy Plan Example

Six Residents a Year for a County With Four Family Physicians: An Administrator Advocacy Plan for a Composite Health System's Vice President of Government Relations Seeking State Medicaid Payments for a New Rural Family Medicine Residency in One Legislative Session

[Student Name]

Purdue University Global

HA545: Health Policy

Unit 9 Administrator Advocacy Plan

[Instructor Name]

[Date]

The health system, the state, the officials and every figure are composite and bracketed for the writer's own data; federal rules described are real.

Goal

In the next state budget, the Medicaid program adds graduate medical education payments of [$95,000] per resident per year for new family medicine residents training at least half their time in rural counties, starting with the system's program in [year].

Background

Medicare pays more toward residency training than any other public source, but most hospitals' funded positions were capped at their 1996 resident counts by the Balanced Budget Act of 1997. A hospital that has never trained residents can build a cap during its first five years of a new program (42 C.F.R. § 413.79, 2024). Congress added [1,000] new Medicare-funded positions in 2020 law, with priority for rural and underserved areas, but competition for them is high. Most states also pay for residency training through Medicaid, at their own choice and in their own amounts. This state does not, which leaves new rural programs short of funds. Research has long found that physicians tend to practice near where they completed residency (Seifer et al., 1995), so where residents train shapes where physicians stay.

The System's Evidence

The rural county has [four] family physicians for [31,000] residents. The system's urban internal medicine program sees [41] percent of graduates practice within [100] miles. At full size, with [18] residents, the rural program's annual budget comes to roughly [$2.9] million; expected Medicare funding covers about [$1.2] million once the cap is built. The state payment would close most of the gap: [18] residents at [$95,000] is [$1.71] million, about [$0.6] million of it state money after the federal Medicaid match. The request is small in the state budget and decisive for whether the program opens at all.

Targets

Medicaid director: decides how GME payments would be structured; can propose them in the agency's budget request. Timing: the agency's request is due in [September]. Chair of the House appropriations health subcommittee: controls the budget line. Timing: hearings in [February]. Governor's health policy adviser: shapes the governor's budget. Timing: [November]. State rural health association: an ally, with members in every rural district.

Messengers

For the Medicaid director: the system's chief medical officer, who can speak to program design and federal matching. For the subcommittee chair: a resident who grew up in a rural county, and the county's hospital board chair, who lives in the chair's district. For the governor's adviser: the rural hospital's chief executive with the rural health association director. Messengers are chosen for credibility with each target, not by rank.

Channels

Meetings with each target; testimony at the budget hearing; a two-page brief; a letter of support from [12] county commissions; local news coverage of the rural physician shortage; and formal comments if the Medicaid agency proposes payment rules.

Anticipated Objections and Answers

Why should the state pay for training that Medicare is supposed to fund? Because Medicare's caps leave new programs short, and most states already supplement Medicare through Medicaid; this state would be catching up, not leading. Will residents stay? Not all will, but rural training tracks in other states retain a meaningful share of graduates nearby, and the system will report where each graduate practices. Why one system's program? The payment would be open to any new rural family medicine residency that meets the criteria, so the request is framed as a state program, with the system's residency as the first user. Will the cost grow? The payment is capped per resident and limited to rural training, so growth follows only new rural programs.

Timeline

[August]: brief written; meeting with the Medicaid director before the agency's request. [October]: rural health association adopts the issue. [November]: meeting with the governor's adviser. [January]: county letters collected; meetings with subcommittee members. [February]: testimony at the budget hearing. [April]: final budget; follow-up with the agency on payment rules.

Limits on Lobbying

As a nonprofit under Section 501(c)(3), the system may lobby only as an insubstantial part of its activities (26 U.S.C. § 501, 2024). It will track staff time and costs spent on legislative lobbying and keep them well within that limit. Comments to the Medicaid agency on how to implement payments, and educational briefings, are generally treated differently from legislative lobbying, but the system's counsel will review all materials. No system funds will go to political campaigns.

Measures of Progress

The Medicaid director's request includes GME payments; the governor's budget includes them; the subcommittee adopts them; the final budget funds them; the agency issues payment rules by [date].

Risks

Budget pressure could push the payment out of the final budget. Fallback: a one-time start-up grant for the program's first [two] years, with a study of permanent funding.

Conclusion

A narrow goal, targeted at the officials who control one budget line and carried by people they trust, gives the system its best chance to open the program on time.

References

42 C.F.R. § 413.79 (2024). https://www.ecfr.gov/current/title-42/section-413.79

Seifer, S. D., Vranizan, K., & Grumbach, K. (1995). Graduate medical education and physician practice location: Implications for physician workforce policy. JAMA, 274(9), 685-691. https://doi.org/10.1001/jama.1995.03530090017015

26 U.S.C. § 501 (2024). https://www.law.cornell.edu/uscode/text/26/501