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: • • • • • • • 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 12 Risk Factors: Adolescent Smoking Cigarette smoking in the past month among adolescents 12-17 years of age by region and rurality, 2010-2011 13 Risk Factors: Adult Smoking Cigarette smoking among persons 18 years of age and older by rurality 14 Risk Factors: Adult Smoking Cigarette smoking among persons 18 years of age and older by region and rurality, 2010-2011 15 Risk Factors: Obesity Obesity among persons 18 years of age and older by rurality 16 Risk Factors: Obesity Obesity among persons 18 years of age and older by region and rurality, 2010-2011 17 Risk Factors: Physical Inactivity Physical inactivity among persons 18 years of age and older by rurality 18 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 20 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 23 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 25 26 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)? • • • • 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!