Residency Slots Are the Rate Limiting Factor of Physician Production to Meet Rural Demand

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1 Rural Impact of Medicaid Expansion and the ACA 40 th Annual Rural Health Conference Prescott, Arizona August 20, 2013 United States - Physician & Health Professions Supply in Rural & Urban Underserved Areas ü 21% U.S. population lives in rural areas ü 10% physicians practice in rural areas ü 58% of rural and 2/3 National Health Service Corps providers are family physicians Daniel Derksen MD Director, Center for Rural Health dderksen@ .arizona.edu Access to Health Care 75% Pop. Lives in Phoenix, Tucson 86% Physicians in Phoenix, Tucson Public Land (55%) Reservation (28%) CHALLENGE: Distribute the health workforce to the areas of high need Predictors of Retention Health professions trainees most likely to practice in rural and underserved areas: Receive training in rural or underserved area Are underrepresented minorities Graduate from primary care training programs Grew up in a rural area Attend high school, college, health professional school, internship / residency in state Residency Slots Are the Rate Limiting Factor of Physician Production to Meet Rural Demand The vast majority of physician training and funding is in urban, tertiary care teaching hospitals Federal Funding of Teaching Hospitals Social Security Act Medicare/Medicaid SSA Entitlement Funding In Billions IME - Indirect Medical Education DGME - Direct Graduate Medical Education % Total Medicare $9.5 71% Medicaid $3.8 29% TOTAL $13.3 B 100% Derksen D, Whelan EM: Closing the Health Workforce Gap: Reforming Federal Health Care Workforce Policies to Meet the Needs of the 21 st Century. Center for American Progress

2 Reforming Health Professions Education Hold teaching hospitals accountable Increase cap high need residency slots Create all payers health professions funding Establish fixed floor Direct GME primary care residency funding at $100,000 per resident (similar to GPCI) Reallocate some Medicare and Medicaid GME to fund community-based interprofessional health professions training in Teaching Health Centers Permanently fund Teaching Health Centers U.S. Health Spending: The Good News : Slowest recorded in history of National Health Expenditure Accounts Cost growth averaged 3.9% year Vorhees, Prado, Epperly, Derksen: Family Medicine. March Accessed 8/18/13 at: Health Affairs January 2013, accessed 4/22/13 at: Average Annual Percent Change National Health Expenditures The Bad News: $85B Cuts/7 Mo. 1. Education $4.1 Billion 2. NIH, Medical Research: $2.5 B 3. Women, Infants, Children: $0.5B Source: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at (see Historical; National Health Expenditures by type of service and source of funds, CY ; file nhe2010.zip). State Scorecard on Health System Performance. The Commonwealth Fund Oct/2009-State-Scorecard.aspx Sequester Effects on AZ AZ ranks #6 in share of DOD contracts $13B/Yr AZ loses $2.3B/Yr and 50,000 jobs Recession Effects on AZ Deficit 2011: $3.2 Billion Ranked 2 nd job loss: 225,000 AZ gained 100,000 jobs

3 U.S. Health Care Coverage Health Insurance Private Health Insurance Government Health Insurance # in millions % pop % % % Uninsured % Total Population % Insurance, Poverty, and Health Insurance Coverage in the United States: US Census Bureau September 2012, accessed 4/22/13 at: Employer Sponsored Insurance Subsidy $268 Billion in 2011 President Obama announced a delay (to 2015) in ACA penalties for large employers who do not offer affordable coverage to their full-time workers ACA can achieve all major objectives without the employer mandate. Urban Institute at: ACA Coverage Estimates CBO Expands Medicaid (<138% FPL) 13 million Creates Marketplaces ( % FPL) 23 million Employer Sponsored + Nongroup Ins -12 million Increase in Insured (by 2023) 24 million Residual Uninsured (in 2023) 32 million Enrollment begins 10/1/13, coverage 1/1/14 In 2014: 7 million will enroll in individual marketplaces and 2 million in Small Business Health Options Plan ACA benefits the rural uninsured ü No pre-existing illness coverage denials ü Gradual elimination of Part D donut hole ü No lifetime or annual limits ü No coverage recissions ü Payment for preventive services CBO s Estimate of the Effects of the Affordable Care Act on Health Insurance Coverage, updated estimate based on large employer penalty delay to Congressional Budget Office. Accessed 8/17/ Accessed 8/4/13 at: Individual Insurance $0.5 Billion ACA Medical Loss Ratio Rebates Accessed 8/14/13 at: 3

4 Health Coverage by Firm Size ü Small business is <50 FTE Employees ü Small businesses pay 18% more than large businesses for same health insurance policy ü 98% firms >200 FTE offer health benefits ü 61% small firms (3-199) offer benefits ü 50% very small businesses (3-9 FTE s) ü #1 Reason for Not Offering: COST SHOP Facts ü <50 FTE Employees ü Small business health care tax credit worth up to 50% of premium costs ü Employer chooses plan, defines employer contribution toward coverage ü Affordable Definition: <9.5% household income or wages as reported on W-2 ü Large employer penalty: $2000 after 30 FTE Coverage by Part Time Status Coverage by Temporary Status Executive Branch: Governors Republican Democrat Total Governors Influence ACA Coverage at State Level ACA Exchange Decisions by State 19 federally facilitated 15 with state help 34 by CMS 16 state exchanges Accessed 8/4/13 at: 4

5 ACA Medicaid Expansion by State All 20 D-Gov Expanding Medicaid; 12/30 R-Gov Current AZ Health Coverage / Insurance Payer Source # Arizonans Medicaid 1,200,000 Uninsured 1,200,000 Medicare 800,000 Private Insurance 3,300,000 Total Pop. AZ 6,500,000 8 R-Gov YES: AZ, FL, MO, ND, NJ, NM, NV, OH 4 R-Gov Alternative: IN, IA, OK, TN Accessed 8/4/13: Accessed 8/12/13 Does Having Medicaid Mean Better Health Outcomes than Being Uninsured? Income < 138% Income >138% to <400% Medicaid/CHIP 13 Million MEDICAID (AHCCCS) <138% FPL ($32,499 family of four) AZ: 300,000 Health Insurance Exchange 23 Million HEALTH INSURANCE MARKETPLACE 138% to 400% FPL ($32,499 to $94,200) AZ: 600,000 AZ Net of 600,000 Uninsured Covered Mortality and Access to Care among Adults after State Medicaid Expansions We compared three states that substantially expanded adult Medicaid eligibility since 2000 (New York, Maine, and Arizona) with neighboring states without expansions. State Medicaid expansions to cover low-income adults were significantly associated with reduced mortality Adapted by Dan Derksen MD from data accessed 8/12/13 at: Sommers et al: NEJM 7/25/12 Bottom 10 States Account for 48% of Total U.S. Uninsured (3-Yr. Avg ) STATE %UNINSURED #UNINSURED 1. TX ,192, NV , FL ,882, NM , GA ,907, CA ,256, SC , AZ ,201, LA , MS ,000 TEN STATE TOTAL 23,634,000 U.S ,183,000 Adapted by Dan Derksen MD from US Census Bureau Data Accessed 8/12/13 at: Ten States Have Half the Nation s Uninsured 9 of These 10 States Have R-Govs Four Are US-Mexico Border States STATE %UNINSURED #UNINSURED 1. TX ,192, NV , FL ,882, NM , GA ,907, CA ,256, SC , AZ ,201, LA , MS ,000 Adapted from US Census Bureau Data Accessed 8/12/13 at: And All Ten States Are in the Southern Third of U.S. 5

6 US-Mexico Border States: High %Uninsured US: 49 Million Uninsured # uninsured in millions % uninsured Non-Hispanic White 21.7m 11.1% Hispanic 15.8m 30.1% Black 7.7m 19.5% Binational Policy Forum on Migration and Global Health Accessed 8/12/13 at: Insurance, Poverty, and Health Insurance Coverage in the United States: US Census Bureau September 2012, accessed 4/22/13 at: Disparities in Health Insurance Coverage Percent Uninsured American Indian 31% Hispanic/Latino 31% White 12% US: 3.1 million Hispanics covered by Medicaid expansion, 1.4 million by Health Insurance Marketplace Our budget promotes repealing Obamacare, replacing it with a better system Rep. Paul Ryan Repeals Affordable Care Act Creates Medicare vouchers Block grants Medicaid to states Narrative: Obamacare will collapse under its own weight Rep. Ryan 8/10/13 Dan Derksen MD Is the goal to repeal Obamacare, or the entire Social Security Act? Each year 45,000 Americans die due to lack of health insurance Each day an Arizonan dies due to lack of health insurance Need for ACA outcome research data to inform policy decisions, and to: ü Compare health outcomes for those covered by Medicaid, in Marketplace, and uninsured ü Evaluate access to health services for routine, urgent, emergency, specialty care ü Determine whether new payment and delivery models improve outcomes, control cost growth (ACO s, PCMH) AJPH 2009: 6