Health Reform for Rural America

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Health Reform for Rural America

• NRHA Agenda

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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.

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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
  access to 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.

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Important for Rural Patients the Rural Economy

• Healthcare is the fastest growing segment of
  rural economy.
• Each rural physician can generate numerous other
  jobs in the local rural economy
• In most rural communities hospitals are the
  largest or second largest employer
• Health care can represent
• 20 of a rural community's
• employment and income.

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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 and
• Equity in reimbursement must occur.

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Workforce Shortage

• Expand National Health Service Corp
• Title VII and Title VIII improvements
• Improve Residency Training Programs
• Medical School Rural Training Tracks
• Lift Caps on Rural Residency Programs
• Meet the Needs of Emergency Medical Services in
  Rural America
• More

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Capitol Hill and Rural Issues

• Briefings
• Senate Rural Health Caucus, Senate Rural
  Coalition, House Blue Dogs, Senate Democratic
  Policy Committee, House Rural Caucus, House Rural
  America Solutions Group, Tuesday Group
• Stakeholder Meetings with Leadership and
  Committees

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Health Reform Update

• Senator Ted Kennedy (1932-2009)
• Health care legacy
• Replacement?
• Current Mass. Law special election
• Governor must change to allow Governor
  appointment, as some other states do
• 60 Votes to eliminate a filibuster in Senate
• Without Kennedy (or replacement)
• Without Sen. Bob Byrd (D-WV) currently in
  hospital
• So, only 58 Democrats total
• Therefore, need some Republican support

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Health Reform Update

• Rumors???
• Dems may split the bill into two sections
• First - Coverage Public Option
• Second - less controversial issues Medicare,
  workforce
• To get it passed without 60 votes
• Budget Reconciliation only needs 51 votes
• Back door or loophole strategy
• Dems Considered same strategy during Clinton
  Administration Health Reform Effort
• Sen. Byrd, a supporter of the bill, said no.

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Other Important Members

• Senate Rural Allies (Caucus)
• Rural W M and E C
• House Blue Dogs
• Senate HELP and FINANCE

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Medicare Provisions

• Critical Access Hospitals
• Reinstate Necessary Provider
• Bed Flexibility
• Lack of HIT funding in Stimulus
• Expand 340B prescription drug program
• Elimination of CAH isolation test for ambulance
  reimbursement
• Recruiting residents and physicians
• Equitable reimbursement for anesthesia services

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Medicare Provisions

• Independent Medicare Advisory Committee (IMAC)or
  Sen. Rockefellers version
• Long-standing problem with rural representation
  on current MedPAC Commission
• Despite statutory requirements
• Carve out for rural safety net providers
• Or, requirement for HRSA/ORHP involvement
• At a very minimum, rural representation

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Medicare Provisions

• Extenders
• GPCI
• Hospital hold harmless
• Section 508 hospital payments
• 2 percent bonus for ambulance payments
• Others (included in document on our table)

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Medicare Provisions

• Rural Health Clinics
• Increase Cap from 77 to 92
• Bringing them closer to CHC cap
• Disproportionate Share Hospitals
• Rural hospitals capped at 12, urban has no cap
• Rural Community Hospital Demonstration Program
• Established by MMA
• Set to end soon, and then must go through HHS
  approval process
• Meanwhile, currently functioning hospitals would
  be forced to close
• Asking to keep them open until HHS decision
  (2011), since they are expected to fully instate
  the program anyway

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• Analysis of the Health Reform Bills

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The Process

• House
• Unified Tri-Committee Bill.
• Senate
• Separate bills reported from Senate HELP
  Committee and Senate Finance Committee.

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Unifying themes

• Expanding access of coverage
• Individual Mandates
• Employer Requirements
• Expansion of Public Programs
• Subsidies to health people get coverage
• Quality measures and patient safety (c/e, VBP)
• Insurance pooling (portability
• and choice)

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Issues that Divide

• Public Plan
• Cost
• Subsidies ( federal poverty level)
• Employer Mandates
• Medicaid Expansion
• Abortion
• Issue that Unites RURAL!

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The Big Issues

• Both bills (HELP and House Tri-Committee bill)
  would require employers to provide health
  insurance to workers and individuals to enroll in
  an employer-based, private or government health
  care insurance plan or face penalties. But there
  are differences in the details.
• Employer Insurance Mandate
• HR 3200 The bill would require employers that do
  not offer coverage to pay a payroll tax equal to
  8 percent of their payroll costs. Certain small
  businesses would be exempt.
• Senate Committee Draft Bill For employers that
  do not provide coverage, the bill would assess a
  fee of 750 per worker per year, or 375 for
  part-timers. Businesses with 25 or fewer
  employees would be exempt.
• Individual Mandate
• HR 3200 The legislation requires individuals, by
  2013, to buy coverage or pay a fine of 2.5
  percent of their income but the fine would be
  capped at the cost of the average plan in their
  area. It offers a hardship exemption.
• Senate Committee Draft Bill The bill would make
  individuals pay a fee of 750 a year if they fail
  to obtain coverage. As with the House version, it
  exempts those who have not qualified for any
  affordable coverage.
• Subsidies
• Both versions would offer subsidies to those with
  an income below 400 percent
• of the poverty level (about 88,000 for a
  family of four and 43,000 for individuals) down
  to the eligibility threshold for Medicaid
  coverage.

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The HELP CommitteeThe Affordable Choices Act

• Require all to have insurance
• Create Health Insurance Exchange (Gateway) - -
  Individuals and Employers can purchase.
• Premium and cost-sharing credits available for up
  to 400 of FPL
• Impose new insurance regulations
• on plans in exchange
• Expand Medicaid to 150 of FPL

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Is it good for rural?

• HELP bill contains very strong workforce
  provisions
• AHEC funding quadrupled
• Strong investment in NHSC
• 340B Expansion

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H.R. 3200,the House Tri-Committee Bill

• 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 to 133 of FPL

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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)

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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
• MedPAC Rural Representation Congressman Walden
  Amendment
• Also protects proposed IMAC, or similar entity
  (Sen. Rockefellers plan) to ensure rural
  representation

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HR 3200 - status

• Ways and Means 16 hour mark, party-line vote.
  One republican amendment accepted.
• Energy and Commerce Finished mark after Blue
  Dog agreement
• House Floor Vote? Sometime in September.

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The Big Question
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Finance Committee

• Traditionally strong rural advocates.
• NRHA strong advocacy and grassroots focus on
  Finance.
• Attempts to Make it a Bipartisan Bill
• Grassley, Snowe, Enzi
• Want to keep bill under 1 trillion
• Dont forget Doctor fix

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Emerging Issue

• Co-Op concept
• Sen. Conrads Co-Op Plan - - Alternative to
  public plan
• Must have enough participation to make it viable
  critical mass.
• May not offer lower premiums but can offer
  choice.
• Only could become important sources of health
  coverage if govt. gets involved (control risk
  pooling, subsidies)

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Our Rural Champions

• Sen. Conrad and Sen. Roberts - - original
  cosponsors of S. 1157
• Ranking Member Sen. Grassley - -Strong Interest
  in Rural GME reform
• Sen. Baucus Focusing on Rural Medicare
  Reimbursement Requested suggestions for
  improving CAH HIT/Nec. Provider

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Many Important Players

• Chairman Baucus Montana
• Senator Grassley Iowa
• Chairman Stark - California
• Senator Wyden - Oregon
• Representative Pomeroy North Dakota
• Senator Bingaman New Mexico
• Senator Lincoln Arkansas
• Senator Enzi -- Wyoming

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Rural America Needs You!

• Join our list serve - - daily updates!
• Check out our website!
• Join our weekly webinars!

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Thank you!

• Danny Fernandez
• Manager, Government Affairs and Policy National
  Rural Health AssociationFernandez_at_nrharural.org