1. Getting Connected: Can the ACA Improve Access to Health Care in Rural Communities? Russell Senate Office Building October 13, 2010 Clint MacKinney, MD, MS RUPRI Center for Rural Health Policy Analysis clintmack@cloudnet.com 320-493-4618

2. 2 Click to edit Master title style ACA – Overview Comprehensive legislation, much more than expanded health insurance coverage, e.g., – Performance measurement and transparency – Clinical quality improvement – Health care workforce support – Linking payment and performance Long implementation timeline (the political and health care landscape will change!). The “angel” is in the (rules/regulations) details. A key to ACA success will be careful analysis and flexibility to modify any implementations with unintended consequences.

3. 3 Click to edit Master title style ACA – Implicit Expectations Near universal coverage. More affordable medical care. Integrated health care delivery models with increased coordination across the care continuum. Improved health care value (improving quality and “bending” the cost curve). Goal for today Quickly review selected ACA impacts on rural people, places, and providers. Describe selected rural ACA highlights, and also some associated cautions.

4. 4 Health Insurance Coverage Currently: – Rural uninsured rates are higher than urban uninsured rates. – Rural incomes are lower than urban incomes. – Greater proportion of rural employed by small business. Small business tax credits for health insurance. Therefore, the ACA will have a disproportionate positive impact on rural people. Assess net impact on small businesses Consider rural realities during enrollment efforts and health insurance exchanges, e.g., – Internet access (for enrollment) – Risk rating (rural = higher risk) – Adequate plan choice – Network standards and usual patterns of care – Rural representation during HIE governance

5. 5 Medicare and Medicaid Payment Geographic practice expense disparity reduction and 10% primary care bonus. Fewer uninsured and decreasing DSH payments. Significant Community Health Center (CHC) program funding increase. Accountable Care Organizations – linking payment to performance. Assess rural eligibility for primary care bonus (only if primary care services > 60%). Monitor if new insurance reimbursements offset DSH payment reductions. To access funds, demonstrate CHC collaboration with other safety net providers. Facilitate rural provider participation in ACOs.

6. 6 Quality, Financing, and Delivery System Reform New (or expanded) centers and commissions to improve health care value. Accelerated quality measurement and transparency. New delivery programs (ACOs), demonstrations (medical homes), and payment systems (bundling). Ensure rural representation on centers and commissions. Design rural relevant measures and consider low volumes, but do not exclude rural providers. Facilitate rural inclusion in new programs and demonstrations.

7. 7 Public Health New National Prevention, Health Promotion, and Public Health Council. New public health fund to support community-based programs. Research focus on public health services and disparities. Ensure rural representation on Council Advisory Group. Consider the importance of community services to rural areas. Include geographic disparities in public health research.

8. 8 Health Care Workforce New grants for health care worker training programs will likely benefit rural places. Student loan repayment is extended to allied health and public health professionals. Ensure that new professional numbers are sufficient to care for the newly insured. Make general surgery eligible for National Health Service Corp support. Encourage team-based care (medical homes) that better utilize existing professionals.

9. 9 Long-Term Care Rural people are more aged, therefore LTC provisions more important to rural. Extended program to assist transition from LTC to home. Community Living Assistance Services and Support Act – a voluntary LTC insurance program. Facilitate outreach to ensure rural LTC insurance enrollment. Consider sliding scale for LTC insurance premiums. Monitor payment change impact on rural providers – especially home health (distance reduces efficiency).

10. 10 Click to edit Master title style ACA – Rural Implementation Questions Are new health insurance exchanges enrolling a proportionate number of rural residents and rural small businesses? Are physician payment changes improving rural provider and primary care shortages? Are rural providers actively participating in new healthcare delivery models and options? Are newly developed quality measures rural relevant and do they consider low volumes? Are ACA workforce provisions actually reducing rural/urban health care professional disparities? Are rural health services researchers evaluating the impacts of the ACA as new provisions are implemented?