Critical Access Hospitals (CAHs) are vital for maintaining access to high-quality health care services in rural communities. Presently, CAHs represent a quarter of all U.S. community hospitals and more than two-thirds of all rural community hospitals. Since creation of the CAH program as part of the 1997 Balanced Budget Act, the American Hospital Association (AHA) has been advocating on behalf of CAHs for program improvements and enhancements. AHA is deeply committed to ensuring the needs of these safety-net hospitals are a national priority.

Below are just some of the ways AHA works for CAHs.


Related Resources

AHA Advocacy Alliance
for Rural Hospitals

AHA Section for Small
or Rural Hospitals

Factsheet: Rural or Small Hospitals

Rural Health Care Homepage

CAH Infographic



Working for Critical Access Hospitals

AHA demonstrates the need for streamlined regulations, common sense rules and manageable timelines, as outlined below.

  • Tracked CMS Guidance on Distance, Location and Regulatory Changes. On Feb. 12, as urged by AHA, the Centers for Medicare & Medicaid Services (CMS) released recertification guidance and a checklist to state survey agency directors indicating that states may immediately use alternative ways to document that a CAH is a necessary provider. AHA is pleased that this new guidance acts on the concerns we expressed to the agency and provides additional flexibility to state survey agencies, which is critical to helping prevent CAHs that rightfully obtained necessary provider status prior to 2006 from losing their CAH designation.

  • Supported Critical Access Hospital Relief Act. AHA shared its support for the Critical Access Hospital Relief Act (S. 258/H.R. 169), which would remove the 96-hour physician certification requirement as a condition of payment for CAHs.

  • Fostered Access to Outpatient Therapeutic Services. For several years, the AHA has successfully advocated for Congress to extend the moratorium on CMS’s enforcement of the agency’s policies related to its “direct supervision” of outpatient therapeutic services furnished in CAHs and rural hospitals with 100 or fewer beds. This annual process is inefficient and so AHA has worked with Congress for a permanent solution. The AHA supports the Rural Hospital Regulatory Relief Act of 2016 (H.R. 5164), which would permanently prohibit the federal government from enforcing its unreasonable supervision regulations for outpatient therapeutic services on CAHs and other small rural hospitals. AHA also supports and continues to work toward passage of the Protecting Access to Rural Therapy Services Act (S. 257/H.R.1611), which would protect access to outpatient therapeutic services by adopting a default standard of “general supervision,” among other provisions.

  • Drove Delay of CMS Release of Star Ratings. Due to significant concerns raised by the AHA and others about whether the hospital quality star rating methodology provides a fair, accurate and meaningful representation of hospital performance, CMS delayed until at least July 2016 the release of overall hospital quality “star ratings” on its Hospital Compare website. AHA will work with CMS to refine its methodology.
  • “Two-midnight” Refinements. In an effort to revise policies with burdensome regulations that divert time and resources away from patient care, AHA helped persuade CMS to finalize several positive changes to its two-midnight policy. In addition, AHA successfully challenged through the courts CMS’s interpretation of its 0.2 percent payment reduction for inpatient services, convincing the agency to restore the resources that hospitals are lawfully due. CMS’s recent IPPS proposed rule for FY 2017 proposes two adjustments to reverse the effects of the cut it unlawfully instituted when implementing the two-midnight policy in FY 2014.
  • Educating Stakeholders on Insurer Consolidation. AHA is working to ensure that the proposed acquisitions involving four of the five major national insurers receive the highest level of scrutiny. AHA has provided analysis to the Department of Justice and testified before Congress numerous times, introducing into the record concrete reasoning why the acquisitions would decrease competition and hurt the marketplace, in addition to working to educate the media and public on the potential consequences for patients and providers.
  • Encouraged Support for the 340B Drug Pricing Program. AHA continues to urge Congress to preserve the 340B Drug Pricing Program. AHA also supports the Health Resources and Services Administration’s (HRSA) efforts to improve the 340B program for eligible hospitals and clinics, including discounts for orphan drugs. In response to its detractors, AHA’s “Setting the Record Straight on 340B” fact sheet separates fact from fiction on the 340B program.

  • Organized Congressional Member and Staff Briefings. Each year, AHA convenes congressional briefings on rural health care issues with key groups. Past meetings occurred with the House of Representatives Subcommittee on Health of the Committee on Ways and Means (Rural Health), House of Representatives Subcommittee on Health of the Committee on Ways and Means (MedPAC Report), Senate Finance Committee Markup on Rural Bills Panel, Senate Rural Health Caucus Briefing on Capitol Hill Panel, and the Senate Committee on Appropriations Subcommittee on Labor, Health and Human Services, Education and Related Agencies (Rural Health).

  • Provided Resources via the Rural Advocacy Action Center. This web-based toolkit provides a set of resources and materials tailored to help hospital executives effectively communicate key messages and explain concerns to legislators, the hospital family and the community at large. For more, visit



Engaging Critical Access Hospital Leaders

CAH leaders have a strong and valued voice in the AHA as they help shape key advocacy activities, policy positions and member services.

  • Task Force and Meetings on Ensuring Access to Care in Vulnerable Communities. The AHA Board created a 30-member task force to focus on ensuring access to care in at-risk communities. The Task Force on Ensuring Access in Vulnerable Communities consists of two subcommittees that are examining the issue from the rural and urban perspectives. The task force has met several times, and listening sessions have been conducted among hospitals in the field. A report to the AHA Board of Trustees is expected in mid-2016.

  • Governance and Policy-Making Roles. AHA offers CAH leaders many opportunities to take an active role in shaping AHA policies and setting direction for the association. CAH leaders can play a formal role in association governance and policy formation by serving on AHA’s Board of Trustees, Regional Policy Boards, Governing Councils and Committees. In addition, the association creates short-term advisory and work groups where members weigh in on more focused, time-sensitive policy issues.

  • AHA Constituency Section for Small or Rural Hospitals. This section has more than 1,800 members, including about 975 CAHs from across the country. It provides forums linking members with shared interests and missions to advise AHA on policy and advocacy activities and to discuss issues of great importance to CAHs and the field as a whole. These efforts are led by the Small or Rural Governing Council, which meets at least three times a year. Valuable opportunities also are provided for CAH leaders to interact and network with one another through special member conference calls and meetings.

  • Advocacy Alliances. advocacy alliancesThe AHA’s Advocacy Alliances provide members with another way to engage legislators on the specific issue or issues that have a direct impact on their ability to continue providing quality health care services in their communities. The Advocacy Alliance for Rural Hospitals focuses on extending Medicare provisions critical to rural hospitals. In addition, this Alliance continues to work to protect CAHs and other rural hospital designations. The Advocacy Alliance for the 340B Drug Pricing Program focuses primarily on preventing attempts to scale back this vital drug discount program.

  • AHA Health Forum Rural Health Care Leadership Conference.This annual conference brings together top thinkers in the field and offers members strategies for accelerating performance excellence and improving the sustainability of rural hospitals.

  • Member Outreach. Several times throughout the year CAH member CEOs are individually contacted by AHA staff and/or are invited to participate in small group CEO conference calls to discuss key AHA initiatives.


Providing Key Resources for Critical Access Hospitals

AHA membership means more than representation on critical regulatory and legislative issues. AHA offers CAHs the tools and resources to navigate today’s changing health care delivery landscape and to support the efforts to improve the quality of care for the communities they serve.

  • Telehealth Resource. AHA offers a web resource with comprehensive information on telehealth. The site includes information on federal and state telehealth initiatives, research documenting telehealth value, AHA-member case studies showing telehealth in action and AHA TrendWatch reports on telehealth benefits to patients. For more, visit

  • Equity of Care. Addressing disparities is essential for performance excellence and improved community health. AHA issued goals and milestones from the National Call to Action, launched in 2011 to end health care disparities and promote diversity, and encourages hospitals to take the#123forEquity Pledge to eliminate health care disparities. For more, visit

  • Veterans Hiring Resource. Hospital Careers: An Opportunity to Hire Veterans is a toolkit for hospitals with guidance on recruiting veterans into hospital careers. The resource aims to assist hospitals hire veterans with clinical experience, as well as talent and leadership skills beyond their medical credentials.
  • Cybersecurity Resource. The AHA invites members to listen to a new cybersecurity audio-cast series, Cyber 911: Responding to a Cybersecurity Breach. By listening to four short dialogues, health care leaders can gain a better understanding of what preparations their organizations need to take to respond effectively when a cybersecurity breach occurs. Each part can be downloaded at
  • HPOE Guides and Reports. AHA’s Hospitals in Pursuit of Excellence shares action guides and role of small rural hospitalsreports to help accelerate performance improvement. For example, The Role of Small and Rural Hospitals and Care Systems in Effective Population Health Partnerships describes how hospitals can develop partnerships that balance the challenges and opportunities encountered in providing health management, and The Second Curve of Population Health builds upon prior AHA reports that outline a road map for hospitals to use as they transition to the second curve of population health.
  • RACTrac. The AHA RACTrac website provides information on the recovery audit contractor (RAC) survey that collects data from hospitals on a quarterly basis to assess the impact of the Medicare RAC program on hospitals. The site also offers webinars and reports that highlight the survey findings and provides access to the RACTrac analyzer tool that compares similar hospitals’ RAC activity.
  • AHA Resource Center. Highly trained information specialists assist members in accessing timely and relevant health services articles and data.




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