Healthcare Issues from the National Perspective 8 th Annual Indiana Rural Health Policy Forum

1. Healthcare Issues from the National Perspective 8th Annual Indiana Rural Health Policy Forum Brock Slabach, FACHENational Rural Health Association

2. Agenda • Healthcare Reform: Current Status • ARRA and Meaningful Use

3. We’ve come a long way, baby • A little over a year ago, just a campaign promise. • Never has “comprehensive” health reform come this close to becoming law. • Largest health bill since Medicare. • T. Roosevelt, 70’s, 90’s.

4. The end is in sight • Hurdle 1: House passes health reform, party line vote. • Hurdle 2: Senate passes health reform on Christmas Eve, party line vote (60-39) • Hurdle 3: Conference Committee (???)

5. 2009 at a Glance Two of three “health reform” steps already finished…

6. Step 1: SCHIP Expansion “Down payment” on health reform Covers an additional 4 million children Lifts ban on providing coverage to children of legal immigrants

7. Step 2: ARRAAmerican Recovery and Reinvestment ActOr Stimulus Bill $787 billion package $87b for Medicaid HIT Investment $1.1b for comp. effect research Includes rural Rural broadband Rural water projects Workforce training Prevention/wellness

8. House Bill • House passed bill (HR 3962) way back in October… • So what took the Senate so long??? • Bills are MUCH easier to pass by leadership (with majority) in the House • No filibuster, thus limiting number of hours of debate before final vote

9. No Christmas for Senate Staff… Senate Voted on Christmas Eve to pass H.R. 3962, the Affordable Health Care For America Act of 2009 Final Vote: 60-39 Procedural hurdles Republican Opposition Filibusters, Cloture

10. Health Reform - - the big Picture Require all to have health insurance Create a Health Insurance Exchange - - Individuals and Employers can purchase. Premium and cost-sharing credits available for up to 400% of FPL Require employers to provide coverage or pay into exchange (small employers exempted) Impose new insurance regulations on plans in exchange Expand Medicaid

11. So…What’s Next? Conference Committee? Usually, held between House and Senate to agree on final version of two similar bills Well…not this time, says Leadership and White House

12. So…What’s Next? • Formal conference will be omitted, and D’s will conduct a “mini-conference” behind closed doors • C-SPAN Letter to Leadership • “Let our cameras in!!!” • Eliminates potential Republican filibuster, and need for cloture, in Senate • NRHA still working with Congress to make sure discussions include rural

13. NRHA Believes… Rural America needs health care reform. Rural America needs health reform done correctly.

14. The Rural Uninsured • A greater proportion of rural residents than urban residents are uninsured or covered through public sources. (23% compared to 19%) • 30% of uninsured rural residents are not employed compared to 27% of urban residents. • For those who are employed - - small firm size, low wages, and self-employment - - continue to be risk factors for higher uninsured rates in the most rural places.

15. Despite that - - the problem in rural health care is ACCESS Health reform that expands health care coverage is necessary - - rural Americans lack insurance at a higher rate than their urban counterparts - - but there is a greater crisis in rural America: accessto health care. Coverage does not equate to access. Over 50 million Americans live in areas where there are too few providers to meet their basic primary care needs. Yet these rural patients face the most daunting of health care challenges: per capita, rural populations are older, poorer and sicker. For health reform to be a success, the access crisis in rural America must first be resolved.

16. The NRHA Solution: To resolve the health care crisis in rural America, the rural health care safety net must be prevented from crumbling. Three reforms are crucial: The workforce shortage crisis must be abated; Equity in reimbursement must occur

17. Senate Rural Positives Workforce: • Rural Physician Training Grants • Expanding Area Health Education Centers (AHEC) • Graduate Medical Education (GME) Improvements • Redistribution of residency slots • National Health Service Corps • Undergraduate medical education • National Health Care Workforce Commission

18. H.R. 3200/Rural Positives • 340B Drug Expansion – CAHs, MDH, SCH, RRC, expand to inpatient drugs. • Primary Care Investment • NHSC • GME grants for expanding residency programs to RHCs and FQHCs • Primary care payment increases – extra 10% bonus for primary care in HPSA. • IOM Study on Geographic Adjustment Factors • Medicare “Extenders” plus: • marriage and family therapists; and • Mental health counselors • Reauthorization of the Indian Health Care Improvement Act • Grants for mental health and substance abuse screening in primary care health care settings. $30 million for grants, contracts, and cooperative agreements. • Establishes an Office of Minority Health in CDC, SAMHSA, AHRQ, HRSA, and FDA

19. The House bill…is it good for Rural? NRHA Concerns: Many Medicare Inequities Not Addressed Residency Redistribution Public Plan Reimbursement Rates Investment in Workforce not sufficient (Title VII, Title VIII, GME provisions omitted)

20. So… • Baring an Earth-Shattering series of events • Bill will likely go to President’s Desk for signature, and therefore pass into law

21. So, We’ve Got Health Reform, Now What? • For Rural, the fight is FAR from over… • As with any huge bill like this, it will need some fixin’

22. So, We’ve Got Health Reform, Now What? • Many positive rural provisions • But, many left out…

23. Outstanding Amendments • Reauthorize the Indian Health Care Improvement Act • Bennet (D-CO) Amendment • CAH HIT • RHC 340B • State Offices • Pryor (D-AR) Amendment • CAH 35-mile waiver • Udall (D-CO) • Workforce/pipeline • Durbin (D-IL) • CRNA (attempt at new score) • Tester (D-MT) • Small, rural hospital financing • Nelson (D-NE) • Rebasing for small hospital demo program.

24. Much work still needs to be done… • Looking forward/fixing current bill • Rural Allies are strong • Harkin (HELP Committee, Senate Rural Health Caucus Chair) • $$$ can be our enemy • The fight continues

25. ARRA and Meaningful Use ONC Issued Recommended MU standards June, 2009 CMS Issued Proposed Regulations December 30, 2009 Comments to CMS Due March 15, 2010

26. Timeline • Oct. 1, 2010: Medicare Incentive payments to Hospitals begin • Jan. 1, 2011: Incentive payments to “eligible professionals” under Medicare • Jan. 1, 2011: Begin and monitor Medicaid incentive payments to hospitals and eligible professionals • Oct. 1, 2015 and after: Initiate payment reductions to Medicare hospitals and eligible professionals that fail to adopt EHRs

27. Actions Needed • Monitor http://Blog.ruralhealthweb.org • Submit a comment letter from your facility to CMS • Return NRHA Survey!

28. MU Survey • Assesses MU Status for Your Hospital • Provides Data to Inform Policy Makers • Targets Needs for Technical Assistance • Basis for Formulation of Legislative Strategy to Fix Key Components of ARRA

29. Survey Details • www.ruralhealthweb.org/hit to download latest version of survey • Submit Survey to http://NRHA.informz.net/survistapro/s.asp?id=2043 • Email: bslabach@nrharural.org • Fax: 816-756-3144

30. Rural America Needs You! • Join our list serve - - daily updates! Join-grassroots@lists.wisc.edu • Check out our website! • Join our weekly webinars!

31. Thank you! Brock Slabach, FACHE Sr. Vice-President, Member Services National Rural Health Associationbslabach@nrharural.org