1. Thursday, September 11, 2014 Michael Meit, MA, MPH Rural Health Disparities: A Baseline for Healthcare Reform & The Future of Rural Public Health

2. 2 Examination of Trends in Rural and Urban Health: Establishing a Baseline for Health Reform CDC published Health United States, 2001 With Urban and Rural Health Chartbook No urban/rural data update since 2001 Purpose of this study: Update of rural health status ten years later to understand trends Provide baseline of rural/urban differences in health status and access to care prior to ACA implementation

3. 3 Methods Replicated analyses conducted in 2001 using most recent data available (2006-2011) Used same data source, when possible: National Vital Statistics System Area Resource File (HRSA) U.S. Census Bureau National Health Interview Survey (NCHS) National Hospital Discharge Survey (NCHS) National Survey on Drug Use and Health (SAMHSA) Treatment Episode Data Set (SAMHSA) Applied same geographic definitions, although classifications may have changed since 2001: Metropolitan Counties: large central, large fringe, small Nonmetropolitan Counties: with a city ≥ 10,000 population, without a city ≥ 10,000 population

4. 4 Counties by Region and Rurality (2006)

5. 5 Population: Age Population 65 years of age and over by rurality

6. 6 Population: Poverty Population in poverty by rurality

7. 7 Mortality: Infants Infant mortality by rurality

8. 8 Mortality: Children and Young Adults Death rates for all causes among persons 1–24 years of age by rurality

9. 9 Mortality: Working-Age Adults Death rates for all causes among persons 25-64 years of age by rurality

10. 10 Mortality: Seniors Death rates for all causes among persons 65 years of age and over by rurality

11. 11 Mortality: Heart Disease Death rates for ischemic heart disease among persons 20 years of age and over by rurality

12. 12 Risk Factors: Adolescent Smoking Cigarette smoking in the past month among adolescents 12-17 years of age by rurality

13. 13 Risk Factors: Adolescent Smoking Cigarette smoking in the past month among adolescents 12-17 years of age by region and rurality, 2010-2011

14. 14 Risk Factors: Adult Smoking Cigarette smoking among persons 18 years of age and older by rurality

15. 15 Risk Factors: Adult Smoking Cigarette smoking among persons 18 years of age and older by region and rurality, 2010-2011

16. 16 Risk Factors: Obesity Obesity among persons 18 years of age and older by rurality

17. 17 Risk Factors: Obesity Obesity among persons 18 years of age and older by region and rurality, 2010-2011

18. 18 Risk Factors: Physical Inactivity Physical inactivity among persons 18 years of age and older by rurality

19. 19 Risk Factors: Physical Inactivity Physical inactivity among persons 18 years of age and older by region and rurality, 2010-2011

20. 20 Mortality: Chronic Obstructive Pulmonary Diseases Death rates for chronic obstructive pulmonary diseases among persons 20 years of age and over by rurality

21. 21 Mortality: Suicide Suicide rates among persons 15 years of age and over by rurality

22. 22 Mortality: Suicide Suicide rates among persons 15 years of age and over by region and rurality, 2008-2010

23. 23 Other Health Status: Adolescent Births Birth rates among adolescents15-19 years of age by rurality

24. 24 Other Health Status: Adolescent Births Birth rates among adolescents15-19 years of age by region and rurality, 2008-2010

25. 25 Conducted on behalf of the Health Resources and Services Administration (HRSA) Federal Office of Rural Health Policy (ORHP) A compilation of evidence-based practices and resources that can strengthen rural health programs New toolkits each year on different topics that target ORHP grantees, future applicants, and rural communities Applicable to organizations with different levels of knowledge and at different stages of implementation Hosted by the Rural Assistance Center on the Community Health Gateway Evidence-Based Models Toolkit Series

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27. The Future of Rural Public Health

28. 28 Categorically Funded/ Siloed ? “Integration of PH and Primary Care” 2014 2024

29. 29 State and Local Public Health State and Local Budget Cuts Reliance on Categorical Federal Funding Changing Environment a la the ACA Accreditation/ Push for Accountability Drivers of Change in PH

30. 30 Funding cuts to health departments (HDs) in wake of recent financial downturn Reduced budgets in all 7 case study HDs participating in NORC PH Financing Study Funding shifts result in program reductions, cuts, and layoffs Unpredictable funding streams and tight budgets present significant challenges to HDs Drivers of Change – Budget Cuts

31. 31 Specific areas where state funds have decreased include state general fund revenues and tobacco Master Settlement Agreement allocations Loss of State General Funds is particularly problematic as they are a flexible funding source Support gaps in categorical funding streams (e.g., infrastructure activities & administrative costs) Support programs with costs higher than dedicated revenues Often used to meet Federal match requirements Drivers of Change – Budget Cuts

32. 32 No increase in federal funding to make up for decreased state and local funding Federal funding has actually decreased, but at slower rate than state decreases, and has thus grown as percentage of total PH revenue Trust for America’s Health reports significant shortfall in funding for core PH services due to cuts at the federal and state/local levels; reports a 15% loss of the state and local PH workforce between ‘08 and ‘11. Drivers of Change – Budget Cuts

33. 33 Rural HDs rely more heavily on state resources as a percentage of overall funds and have less access to local resources. Rural HDs have more sensitivity to budget cuts as staff tend to work in multiple program areas, and each program is a “touch point” that helps support others. Budget cuts – A Rural Lens Rural Public Health Financing Study: Proportion of HD Resources by Source * * 2008 data

34. 34 State and Local Public Health State and Local Budget Cuts Reliance on Categorical Federal Funding Changing Environment a la the ACA Accreditation/ Push for Accountability Drivers of Change in PH

35. 35 Federal funding is a significant portion of HD revenue Between 57.5 – 74.7% of total revenue in 5 of the case study HDs Third party reimbursement is a small but growing proportion of state funding for PH; fees and fines ranged from.1% to 9.6% of revenue Smaller percentage of revenue from state sources, fees, fines, and other sources HDs’ largest percentage of federal revenue from USDA, followed by CDC, HRSA, EPA, and DHS. Drivers of Change – Reliance on Federal Funding

36. 36 Drivers of Change – Reliance on Federal Funding Federal PH expenditures often vary based upon emerging needs Example: Pandemic flu funding following H1N1 Federal PH expenditures are typically categorical in nature, and may not correspond well to local needs Federal PH expenditures can get tied up in politics Example: NPHII Funding

37. 37 Rural HDs rely more heavily on federal pass through resources as a percentage of overall funds. Fewer local resources, combined with greater reliance on state and federal resources = less flexibility Federal Funding – A Rural Lens Rural Public Health Financing Study: Proportion of HD Resources by Source * * 2008 data

38. 38 State and Local Public Health State and Local Budget Cuts Reliance on Categorical Federal Funding Changing Environment a la the ACA Accreditation/ Push for Accountability Drivers of Change in PH

39. 39 Drivers of Change – The Affordable Care Act The ACA expands insurance coverage and coverage of clinical preventive services The ACA shifts responsibility for some HD services to the provider setting As demand for HHS-funded preventive services programs shifts, so may the categorical funding States in NORC’s ACA Impacts studies have already reported reduced volume in breast and cervical cancer screening programs and in immunization programs. CDC funds for immunization have already been reduced, and other programs may follow. –Are resources sufficient to serve a high-need remaining uninsured population? –Do LHDs enter the marketplace as a provider? If so, will reimbursement cover the costs?

40. 40 Drivers of Change – The Affordable Care Act The ACA may create new opportunities for health departments Expansion of direct services –Contracting and billing –Care coordination Expansion of population health services –ACOs Does funding for PH shift from CDC to CMS? What are the implications?

41. 41 Rural HDs rely more heavily on clinical services as a source of revenue. Does this position rural HDs better, or put rural HDs in competition with other providers? Are rural HDs prepared to operate under this new “business model”? Assume risk? Compete on price? ACA Impacts – A Rural Lens Rural Public Health Financing Study: Proportion of HD Resources by Source * * 2008 data

42. 42 State and Local Public Health State and Local Budget Cuts Reliance on Categorical Federal Funding Changing Environment a la the ACA Accreditation/ Push for Accountability Drivers of Change in PH

43. 43 Drivers of Change – Accreditation & Accountability Key goal of accreditation is to provide a standard set of measures upon which HDs will be evaluated; that is, to help bring consistency to the field. Clinical services will not be considered as documentation of PHAB standards and measures. Some concern among HDs in NORC’s ACA Impacts study that funding will be tied to accreditation at some point. Concurrent with PHAB, federal agencies are demanding more accountability for limited PH resources – “outcomes” is the new buzz word.

44. 44 What does accreditation mean for rural HDs given that they are more heavily engaged in clinical services? In general, will rural HDs apply for accreditation? What does accountability mean for rural HDs given small numbers issues and an insufficient rural evidence base? Accreditation & Accountability – A Rural Lens Source: NACCHO, 2010 National Profile of Local Health Departments

45. 45 Categorically Funded/ Siloed ? “Integration of PH and Primary Care” 2014 2024

46. 46 What information do you need to plan for the future (to look inside the black box)? Changes to the number of uninsured Numbers of individuals who will opt out, or not qualify Provider availability and participation Stability of funding for PH activities Are there strategic actions that HDs can take to leverage opportunities & ensure their stability? Assessing vulnerability of HD programs and developing contingencies Diversifying funding sources Expanding partnerships The Proactive Response

47. 47 PH Strategic Planning High Value Rural PH Services What are HV Rural PH services? STD, TB, Epi/Lab What is the current support for these svs? What are strategies to sustain these svs? New Opportunities via ACA What are new opportunities for PH under ACA? Do they contribute to sustaining and/or supporting HV PH services?

48. Thank You!