Rural Health
Disparities: A Baseline
for Healthcare Reform
&
The Future of Rural
Public Health
Thursday, September 11, 2014
Michael Meit, MA, MPH
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
2
Methods
• Replicated analyses conducted in 2001 using most recent data
available (2006-2011)
• Used same data source, when possible:
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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
3
Counties by Region and Rurality (2006)
4
Population: Age
Population 65 years of age and over by rurality
5
Population: Poverty
Population in poverty by rurality
6
Mortality: Infants
Infant mortality by rurality
7
Mortality: Children and Young Adults
Death rates for all causes among persons 1–24 years of age by
rurality
8
Mortality: Working-Age Adults
Death rates for all causes among persons 25-64 years of age by
rurality
9
Mortality: Seniors
Death rates for all causes among persons 65 years of age and
over by rurality
10
Mortality: Heart Disease
Death rates for ischemic heart disease among persons 20 years
of age and over by rurality
11
Risk Factors: Adolescent Smoking
Cigarette smoking in the past month among adolescents 12-17
years of age by rurality
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Risk Factors: Adolescent Smoking
Cigarette smoking in the past month among adolescents 12-17
years of age by region and rurality, 2010-2011
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Risk Factors: Adult Smoking
Cigarette smoking among persons 18 years of age and older by
rurality
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Risk Factors: Adult Smoking
Cigarette smoking among persons 18 years of age and older by
region and rurality, 2010-2011
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Risk Factors: Obesity
Obesity among persons 18 years of age and older by rurality
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Risk Factors: Obesity
Obesity among persons 18 years of age and older by region and
rurality, 2010-2011
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Risk Factors: Physical Inactivity
Physical inactivity among persons 18 years of age and older by
rurality
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Risk Factors: Physical Inactivity
Physical inactivity among persons 18 years of age and older by
region and rurality, 2010-2011
19
Mortality: Chronic Obstructive Pulmonary
Diseases
Death rates for chronic obstructive pulmonary diseases among
persons 20 years of age and over by rurality
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Mortality: Suicide
Suicide rates among persons 15 years of age and over by rurality
21
Mortality: Suicide
Suicide rates among persons 15 years of age and over by region
and rurality, 2008-2010
22
Other Health Status: Adolescent Births
Birth rates among adolescents15-19 years of age by rurality
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Other Health Status: Adolescent Births
Birth rates among adolescents15-19 years of age by region and
rurality, 2008-2010
24
Evidence-Based Models
Toolkit Series
• 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
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The Future of Rural Public Health
2014
Categorically
Funded/
Siloed
2024
?
“Integration
of PH and
Primary
Care”
28
Drivers of Change in PH
Reliance on
Categorical
Federal
Funding
State and
Local Budget
Cuts
Changing
Environment
a la the ACA
State and
Local
Public
Health
Accreditation/
Push for
Accountability
29
Drivers of Change – Budget
Cuts
• 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
30
Drivers of Change – Budget
Cuts
• 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
31
Drivers of Change – Budget
Cuts
• 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.
32
Budget cuts – A Rural Lens
• 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.
Rural Public Health Financing Study:
Proportion of HD Resources by Source *
Rural
Micropolitan
Urban
0
10
Local
20
30
State direct
40
50
60
Federal pass-through
70
80
Federal direct
90
100
Clinical
* 2008 data
33
Drivers of Change in PH
Reliance on
Categorical
Federal
Funding
State and
Local Budget
Cuts
Changing
Environment
a la the ACA
State and
Local
Public
Health
Accreditation/
Push for
Accountability
34
Drivers of Change – Reliance
on Federal Funding
• 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.
35
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
36
Federal Funding – A Rural
Lens
• 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
Rural Public Health Financing Study:
Proportion of HD Resources by Source *
Rural
Micropolitan
Urban
0
10
Local
20
30
State direct
40
50
60
Federal pass-through
70
80
Federal direct
90
100
Clinical
* 2008 data
37
Drivers of Change in PH
Reliance on
Categorical
Federal
Funding
State and
Local Budget
Cuts
Changing
Environment
a la the ACA
State and
Local
Public
Health
Accreditation/
Push for
Accountability
38
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?
39
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?
40
ACA Impacts – A Rural Lens
• 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?
Rural Public Health Financing Study:
Proportion of HD Resources by Source *
Rural
Micropolitan
Urban
0
10
Local
20
30
State direct
40
50
60
Federal pass-through
70
80
Federal direct
90
100
Clinical
* 2008 data
41
Drivers of Change in PH
Reliance on
Categorical
Federal
Funding
State and
Local Budget
Cuts
Changing
Environment
a la the ACA
State and
Local
Public
Health
Accreditation/
Push for
Accountability
42
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.
43
Accreditation & Accountability
– A Rural Lens
• 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?
Source: NACCHO, 2010 National Profile of Local Health Departments
44
2014
Categorically
Funded/
Siloed
2024
?
“Integration
of PH and
Primary
Care”
45
The Proactive Response
• What information do you need to plan for the future
(to look inside the black box)?
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•
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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
46
PH Strategic Planning
High Value Rural
PH Services
New Opportunities
via ACA
• What are HV Rural
PH services?
• What are new
opportunities for PH
under ACA?
• Do they contribute to
sustaining and/or
supporting HV PH
services?
•
STD, TB, Epi/Lab
• What is the current
support for these
svs?
• What are strategies
to sustain these
svs?
47
Thank You!