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

Russell Senate Office BuildingOctober 13, 2010

Clint MacKinney, MD, MSRUPRI Center for Rural Health Policy Analysis

clintmack@cloudnet.com320-493-4618

2

Click to edit Master title styleACA – 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

Click to edit Master title styleACA – 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

Click to edit Master title styleACA – 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?