Getting Connected : Can the ACA Improve Access to Health Care in Rural Communities?

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. 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. 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. 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. 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. 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. 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. 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. 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. 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?