Federal Policy Update: California SRHA Conference

1. Federal Policy Update:California SRHA Conference Tim Fry, Government Affairs Manager National Rural Health Association Fry@NRHArural.org / 703-519-7910

2. Agenda • Legislative Update • How/why we got here • Regulatory Update • Be a Successful Advocate

3. NRHA Mission The National Rural Health Association is a national membership organization with more than 18,000 members whose mission is to improve the health of rural Americans and to provide leadership on rural issues through advocacy, communications, education and research.

5. Legislative Update • SCHIP • Appropriations or Funding • Medicare • Farm Bill • Public Health Service Act

6. SCHIP and Health Package • State Children’s Health Insurance Program • Been extended twice • Millions of kids could lose health coverage • Rural kids are disproportionately on the program

7. 46 Million Uninsured;8.3 Million Children Rural residents are more likely to be uninsured than urban resident (24% without insurance in rural areas not adjacent to an urban area as compared to 18% in urban areas.) Sources: U.S. Census Bureau; Kaiser Family Foundation analysis of 1998 data.

8. President twice vetoed Short of override in House both times Would have provided $35 billion in additional funding Is there time for another deal? Extension? Tweaks to get more Republicans? SCHIP Update

9. Appropriations/Funding 4th year in a row President proposes massive cuts: Flexibility Grants Outreach & Network Area Health Education Centers Geriatric Programs

10. Appropriations Update • Congress passed better #s than previous years • President vetoed – 2 votes short in House • What’s next? CR? Split the difference? Rural impact?

11. Medicare Package Update • Fix the SGR Cut for Docs • House passed Medicare with SCHIP along 224-201 vote • Expect the Senate to introduce this week • MA Cuts? Timeline?

12. Rural Package • MMA Extenders • Increase to the rural DSH Cap • Rural MedPAC Representation • Other Provisions of the H-CARE or Craig Thomas Bills…

13. Farm Bill • Rural Development – not just commodities • House provides IT and Quality grants • Senate to provide small rural hospital loans • Conference?

14. Workforce Development Public Health Service Act – in Senate cmte. this fall National Health Service Corp expansion Outreach & Network Grants Title VII and VIII – next year? In 2006, reauthorized the Conrad 30 program Source: The National Advisory Committee on Rural Health and Human Services, “Medicare Reform: A Rural Perspective,” May 2001.

15. Why/How We Got Here • New Leadership • New Focus? • Monetary Uses • Presidential elections

16. The 110th Congress The Balance of Power Shifted House of Representatives: 110th Congress has 233 Democrats and 202 Republicans.The 109th Congress had 203 Democrats and 232 Republicans. Senate: 110th Congress has 51 Democrats and 49 Republicans. The 109th Congress had 45 Democrats and 55 Republicans. It has still been hard to gather a majority of votes, particularly in the Senate.

17. Leadership House Nancy Pelosi (CA), Steny Hoyer (MD), Jim Clyburn (SC), Rahm Emanuel (IL) John Boehner (IL), Roy Blunt (MO) • Senate • Harry Reid (NV), Richard Durbin (IL) • Mitch McConnell (KY), Trent Lott (MS)

18. Health Committee Chairmen & Ranking Members House Appropriations: Dave Obey (D-WI) and Jerry Lewis (R-CA); Labor/HHS Subcommittee, Dave Obey and Jim Walsh (R-NY). House Ways and Means: Charlie Rangel (D-NY) and Jim McCrery (R-LA); W&M Health Subcommittee, Pete Stark (D-CA) and Dave Camp (R-MI) House Energy and Commerce: John Dingell (D-MI) and Joe Barton (R-TX); E&C Health Subcommittee, Frank Pallone (D-NJ) and Nathan Deal (R-GA). Senate Appropriations: Robert Byrd (D-WV) and Thad Cochran (R-MS); Labor/HHS Subcommittee, Tom Harkin (D-IA) and Arlen Specter (R-PA) Senate Finance: Max Baucus (D-MT) and Charles Grassley (R-IA) Senate HELP: Ted Kennedy (D-MA) and Mike Enzi (R-WY)

19. HRHCC and SRHC House Rural Health Care Coalition Co-Chairs: Earl Pomeroy (D-ND) and Greg Walden (R-OR) Had 174 Members; 146 reelected; 28 retired or lost election – approximately 180 today Senate Rural Health Caucus Co-Chairs: Tom Harkin (D-IA) and Pat Roberts (R-KS) (Craig Thomas (R-WY) has passed away) Had 76 Senators; 7 retired or lost election, 5 new adds

20. Senators Feinstein and Boxer • Caucus Members • Boxer up in 2010 • Feinstein up in 2012 • Feinstein member of Appropriations Cmte

21. Representatives • Largest Delegation in Congress • Coalition Members: • Mike Thompson (D-1) • John Doolittle (R-4) • Pete Stark (D-13) • Dennis Cardoza (R-21)

22. Representatives (Cont.) • Coalition • Dennis Cardoza (D-18) • Devin Nunes (R-21) • Wally Herger (R-23) • Buck McKeon (R-25) • Jerry Lewis (R-41) • Important Cmtes • Appropriations – 6, inc. ranking member Lewis • E&C – 7 • W&M – 5, inc. Chair of Health Subcmte, Stark

23. Landscape • So new leadership • Stereotype - liberals spend and typically like health care for all Americans • What could go wrong?

24. Health Care Not Top Focus • Biggest priority in Washington is over the conduct and the future of Iraq

25. Why is there not more money? Deficits Commitment to balancing the budget Spending on Homeland Security and War on Terrorism

26. Presidential Election • Lame Duck President • Unwillingness on both sides for negotiation • Tricky health issues may just wait till there is a new President to negotiate with

27. Regulatory Update • CAH Issues • Hospital IPPS • Physicians • Pharmacy • Hospital VBP Report

28. CAH Interpretative Guidelines • Originally issued in 2005, CMS reissued this fall with new language • 75% Rule improved • Concerns with re-certification of application criteria • Even construction on same campus will be considered relocation

29. Final Rule for CAHs • After January 1 – new restrictions • No new collocation with other hospitals • Outpatient provider based clinics must be 35 miles from other hospital to open • De facto ban for “necessary provider” CAHs • CMS exempted RHCs

30. Hospital IPPS • Commented June 12 on the fast implementation • Began October 1 • Severity adjusted DRG • Must notify patients if there is not a physician on site 24/7

31. Physicians • NRHA commented August 31 – has been finalized • 9.9 percent cut – but as explained we expect Congress to attempt a fix • More money used in the PQRI system • Transition to end fax exemption for e-Prescribing

32. Pharmacists • New Requirement – tamper proof prescriptions or Medicaid will not reimburse beginning this spring • Part of War Supplemental in May • Used as offset for Medicaid IGT – NRHA lobbied for

33. CMS Report on Hospital VBP • Released Nov 21 • A pay-for-performance scheme • Clinical and Patient Satisfaction Studies • Only for hospitals on PPS • Congress to act?

35. How you can change Washington, D.C! • Don’t underestimate what you can do. • It’s easy and you can make a difference. A phone call or e-mail can do a lot. • Follow the Five Rules of Lobbying...

36. 1. Have an ask • Don’t want to say “no” • Experts at avoiding this • Easy to get caught up into a discussion of your facility and never about how to help. • Make specific, support x.

37. 2. Explain Importance to District • How is this important to your state/district? • Personalize it • They want to help their constituents

38. 3. Talk to Decision Maker • Go to event where Senator/Representative is and ask in person • Get an email or call to health staffer – leave message with health L.A. NOT the front desk • John.doe@mail.house.gov or jane_doe@senator.senate.gov

39. 4. Know who you are Lobbying • Hill staffers are usually younger than you may expect – still important • Where is bill? What committee? Is person newbie or experienced? • Don’t assume anything!

40. 5. Be Concise and Follow-Up • Be Polite! • Understand time constraint • Follow-up by email

41. Thank you. Tim Fry, Government Affairs Manager National Rural Health Association Fry@NRHArural.org / 703-519-7910