Slide 1

Report
and the
2005 Report to the Secretary
Committee Background



NAC is a 21-member citizens' panel of
nationally recognized rural health and human
service experts
Chartered in 1987 to advise the Secretary on
ways to address health and human service
problems in rural America
NAC primarily advises the Secretary by
producing an annual report with
recommendations on key and timely rural
issues
Committee Members

The Committee is chaired by former South Carolina
Governor David Beasley. The Committee's private and
public-sector members reflect wide-ranging, first-hand
experience with rural issues (in medicine, nursing,
administration, finance, law, research, business, etc.).
Susan Birch
Dr. Joellen Edwards
Bessie Freeman-Watson
Julia Hayes
Michael Meit
Ron L. Nelson
The Honorable Larry Otis
Senator Raymond Rawson
Heather Reed
Evan S. Dillard
Dr. Michael Enright
Joseph D. Gallegos
Dr. Len Kaye
Arlene Jackson Montgomery
Sister Janice Otis
Dr. Patti J. Patterson
Dr. Thomas C. Rickett
Tim Size
The Annual Report Process

At the start of each year, the Committee selects 1-4
issues on which to focus

In February, NAC meets in DC to discuss issues
from a national perspective and hear from health
and human service experts and people within the
Department

In June and September, NAC meets in the field to
continue work on issues and conduct site visits and
hear presentations from host communities
The 2005 Report

Four issues (chapters)

Collaborations to Enhance
Community and Population
Well-Being

Access to Obstetrical Services
in Rural Communities

Obesity in Rural Communities

Welfare Reform in Rural
Communities
To produce the 2005 report…

February 2004: Washington, DC

June 2004: Nebraska City, NE

September 2004: Tupelo, Mississippi
Committee conducts much of work by dividing into
subcommittees to address the various issues. Subcommittees
hold multiple conference calls throughout the year to work on
report.
Collaborations to Enhance Community
and Population Well-Being
*Keith Mueller, Tim Size, Joe Gallegos, Len Kaye, Larry Otis
Purpose of Chapter: to suggest a policy and
program agenda for HHS that would foster
collaboration among community organizations
and local rural leaders to improve the wellbeing of the community and its residents
NAC believes sustaining rural communities requires
effective local collaborations that involve federally
funded programs and payment systems
Collaboration:
Why the Committee Chose this Topic

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More than 225 HHS programs available to
rural communities
Coordination is especially important in rural
communities where resources, services, and
providers are often limited
IOM’s Six Aims to Community Collaboration

Safe, effective, patient and community centered,
timely, efficient, equitable
Collaborations that Work:
Examples

CREATE in Tupelo, MS

Blue Valley Community Action Partnership –
community-based, non-profit serving 15
counties in rural NE And KS; offers more than
30 programs in health services, child
development, emergency services, etc.
Collaborations that Work:
Barriers
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Lack of investment by involved parties
Lack of resources
Long distance travel
Community resistance
Lack of established lines of communication
Collaborations do not occur overnight
Collaborations that Work:
Incentives
1.
2.
3.
4.
BETTER SERVE THE CLIENT
Efficient use of resources
Creating a link between collaboration and
broad goals of the community
Encourage and facilitate efforts of strong
local leaders
*Strong leadership is precondition for successful collaborations.
Communities should strive to always support local leaders,
capture wealth transfer, energize entrepreneurship, and
attract young people
Collaboration:
The Role of Health and Human Services in
Integrating Programs Across Sectors

Health sector is critical in achieving new
directions in rural policy

Importance of thinking of health and human
service programs and policies as integral to
overall community development and rural
economies
Actions and Specific Recommendations
to Facilitate Collaborations
HHS can help establish a policy environment in which
collaboration flourish
ACTIONS:
 Create common reporting requirements for
programs that are linked at the local level
 Encourage programs in other Federal agencies to
participate in multi-sector collaborations
 Facilitate interagency cooperation that allows for
single lines of accountability for funds
RECOMMENDATIONS

The Secretary should support the creation of
a Web resource for “models that work,”
showing successful collaborations in rural
areas (build this into www.raconline.org)

The Secretary should support research that
will further specify opportunities and barriers
RECOMMENDATIONS
(cont.)

The Secretary should support leadership
development for rural community
organizations and residents

The Secretary should require grant recipients
engaged in direct delivery of services to
demonstrate an effect on community
development
Access to Obstetrical Services in
Rural Communities
*Glenn Steele, Evan Dillard, Michael Enright, Heather Reed,
Dave Berk, Julia Hayes, Tom Ricketts

Why the Committee Chose this Topic:
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Growing concern for the viability of OB in rural
areas
Challenges of sustaining OB services in rural
areas
General concern about disparity in distribution of
OB services between urban and rural
Importance of OB to the community
Obstetrics:
What We Know
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OB services in rural areas differ greatly from
place to place
Obstetricians not found in most small rural
and frontier communities; and number is
decreasing since early 1980s
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Low birth rates
Professional isolation
Lifestyle issues
When specialized OB care is unavailable,
rely on family physicians, CNWs, etc.
Obstetrics:
Major Issues
1. Workforce issues
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Supply -OBGYNs/10,000 women ages 15-44 :
Urban: 6.59; Rural: 3.30
Lifestyle: Harsh demands of rural obstetrics; family
physicians who practice obstetrics get burnout, with
no one to replace them
Gender Shift: more women, not attracted to rural
practice
Training: not enough opportunities to maintain skills
(i.e. with Cesarean sections) due to low volume
Obstetrics:
Major Issues (cont.)
2. Rural Hospitals - Low reimbursement rates
for rural hospitals for OB under Medicaid
3. Malpractice Insurance - Much debate on
this, but in some states, physicians say
increase in insurance is primary reason for
abandoning OB care
4. Low Birth Rates and Outcomes Declining birth rates in rural communities –
makes OB care hard to sustain
Rural Obstetrics:
Federal Programs

Several HHS programs, such as:
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Health Community Access Program
Network Program in ORHP
Maternal and Child Health Services Block Grant
1995 Federal Torts Claims Act – extended full
med mal coverage for FQHCs
RECOMMENDATIONS
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The Secretary should increase support for medical
schools that have distinct programs and a proven
track record for training physicians to practice
obstetrics in rural areas
The Secretary should make the recruitment and
placement of physicians trained in obstetrics a
major goal for the National Health Service Corps
The Secretary should support programs to create
hospital and physician networks that will sustain
and improve access to OB services in rural areas
RECOMMENDATIONS (cont.)
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The Secretary should use existing authorities
under Section 301 of the PHSA to promote the
development of team approaches to OB care
involving physicians, nurse practitioners, CNMs,
and other non-physician providers
The Secretary should work toward increasing
Medicaid payments for OB services
The Secretary should address the malpractice
insurance issue by supporting legislation that will
extend the FTCA to rural OB providers in federally
designated shortage areas
Obesity in Rural Communities
*Ron Nelson, Ray Rawson, Sister Janice Otis, Patti Patterson,
Michael Meit, Arlene Montgomery, Joellen Edwards

Why the Committee Chose this Topic:
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Alarming increase in obesity nationwide makes it
one of most important health and social issues of
our time (64% of Americans are overweight)
CDC predicts that if current trends continue, our
children will be first generation in history with
shorter life expectancy than their parents
High medical costs of treating obesity related
diseases, especially burdensome to States
Obesity:
Why it is Important in Rural America
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Health status and availability of health
services are worse in rural America for almost
any disease or health issue – obesity is not
exception
Rural Hospitals: only recently reimbursed for
obesity-related services; some rural hospitals
may be unaware of this change
Rural = higher poverty; poverty is a
determinant of nutritional quality and poor
health; more likely to be overweight or obese
Rural Obesity:
What We Know
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Rural Americans have higher incidence of
obesity than urban counterparts
Obesity is now more common in rural, lowincome populations
Cultural influences in rural areas often
contribute to obesity
Rural Obesity: What We Know
Increase in Overweight and Obesity Prevalence Among U.S.
Adults* by Racial / Ethnic Group
Racial / Ethnic
Group
Black
(non-Hispanic)
Mexican
American
White
(non-Hispanic)
Overweight
Obesity
(BMI > 25)
Prevalence (%)
(BMI > 30)
Prevalence (%)
1988 to 1994 1999 to 2000 1988 to 1994 1999 to 2000
62.5
69.6
30.2
39.9
67.4
73.4
28.4
34.4
52.6
62.3
21.2
28.7
Source: CDC, National Center for Health Statistics, National Health and Nutrition Examination Survey. Flegal et. al. JAMA.
2002; 288:1723-7 and IJO. 1998;22:39-47. *Ages 20 and older for 1999 to 2000 and ages 20 to 74 for 1988 to 1994 .
Addressing Rural Obesity:
HHS Role
Several HHS Programs, such as:
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Healthy Lifestyles and Disease Prevention
Program (www.smallstep.gov) – national
education campaign
Steps to a HealthierUS community grant program;
in 2003, total of $13.7 million awarded through 12
grants to States to fun local efforts to encourage
activity, nutrition, and no tobacco use
CDC administers the Overweight and Obesity
State Program
Addressing Rural Obesity:
Shortcomings of Current Response
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Medicare now reimburses for obesity,
Medicaid does not
Need for greater emphasis on prevention
Not enough support for rural issues in relation
to obesity – i.e. some grant/program
guidance defines “small” community as one
with pop. of fewer than 800,000 people
RECOMMENDATIONS
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The Secretary should encourage the States
to revise Medicaid policy. Medicaid should
follow Medicare and remove all references
to obesity not being an illness.
The Secretary should make refinements to
the HealthierUS community grant program
so that rural concerns can be more
thoroughly represented
RECOMMENDATIONS (cont.)
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The Secretary should ensure that the next
publication of the CDC Chartbook includes
more rural-specific data and that other,
future publications include references to
rural
The Secretary should ensure that rural
residents are seen as a separate and
unique segment of the population in
funding, research, and data collection
Welfare Reform in Rural Communities
*Bessie Freeman-Watson, Jim Agras, Sue Birch, Stephanie
Bailey, Sally Richardson
Introduction:
 In 1996, Congress passed the Personal
Responsibility and Work Opportunity
Reconciliation Act (PRWORA), changing
the nation’s welfare system from an
entitlement program to a block grant
 Programs such as Aid to Families with
Dependent Children were replaced with
Temporary Assistance for Needy Families
(TANF)
Introduction to Welfare Reform

No longer was welfare designed to provide
income maintenance; focus now is moving
people into work

$16.5 billion dollar block grant to the States
gave the States significant programming
authority – they could decide how they want
to design their welfare programs
Introduction to Welfare Reform
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Although much authority now in the hands of the
States, national requirements were set on States
and welfare participants:
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States must maintain their pre-TANF funding levels
States must have a certain percentage of participants
in the workforce
Participants have a five-year lifetime limit on receipt
of cash assistance
Participants must spend at least 30 hours a week
fulfilling work requirement
Welfare Reform: Why the
Committee Chose This Topic
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Since the passage of welfare reform, national studies
have reported large number of recipients find work and
leave welfare; however….
The picture of welfare reform varies dramatically across
the country, with many welfare recipients located in
areas of persistent poverty
Approximately 14% of the nation’s welfare recipients live
in rural areas
We should not only be concerned with decreasing
caseloads. We need to know what happens to
individuals after they leave welfare. Are they still living in
poverty?
Welfare Reform: Why the
Committee Chose This Topic

The Committee wanted to see how welfare
reform has played out in rural areas, for rural
areas, taken as a whole, have:
 Greater rates of poverty
 Higher unemployment
 Lower education levels
 Less access to services

This topic is timely because TANF
reauthorization is currently pending in Congress.
Rural Policy Research Institute. Welfare Reform in Rural America:
A Review of Current Research. P2001-5. February 2, 2001
Welfare Reform:
What We Know
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TANF recipients often face many barriers to moving
into the workforce and off of welfare:
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Lack of transportation
Lack of child care
Low education levels
Substance abuse
Mental illness
Domestic violence
disability
Some barriers are even greater in rural areas…
Rural Obstacles to Success
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Transportation: often cited as #1 obstacle; 80% of
rural areas have no public bus system (compared to
only 2% of urban areas); number 1 means of
transportation in rural areas is personal vehicles BUT
almost 57 percent of the rural poor do not own a car
Child care: essential to getting TANF parents to work,
but it is expensive; many TANF parents work irregular
hours (nights and weekends) and no child care is
available at those times
Labor Markets: Finding a job in rural areas can be
hard for rural labor markets have slower job growth,
higher unemployment rates than national averages
(Example: In Mississippi – only one job available for
every two TANF recipients who needed work); also
often low number of education and training
opportunities in rural areas
Welfare Reform:
The HHS and Federal Role
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Administration for Children and Families
(ACF) – administers the TANF program
ACF promotes best practices, including best
practices in rural areas
Earned Income Tax Credit – a refundable tax
credit available to low-income employees. In
1996, the EITC provided rural areas with an
estimated 6 billion dollars.
RECOMMENDATIONS


The Secretary should work with the
Administration for Children and Families to
provided targeted technical assistance that
would encourage States to address the
transportation, child care, and employment
and training needs of rural TANF recipients
The Secretary should emphasize
collaboration and encourage States to utilize
best practicies, including those identified by
ACF
RECOMMENDATIONS (cont.)

The Secretary should strengthen the Department’s
leadership among Federal partnerships and
collaborations, such as
 Lead the Coordinating Council on Access and
Mobility to address the transportation needs of
rural TANF recipients
 Address the need for more child care services by
coordinating with Head Start and Early Head Start
 Work with the IRS to strengthen the Earned
Income Tax Credit outreach efforts to rural lowincome families
The National Advisory Committee on
Rural Health and Human Services
Topics for the 2006
Report
1.
2.
3.
Access to Pharmaceuticals
in Rural Areas
Health Information
Technology in Rural Areas
The Family Caregiver
Support Program for Rural
Families and Elderly
The National Advisory Committee on
Rural Health and Human Services
Ways You Can Be Involved with the Committee
All of the Committee’s meetings are open to the public, and at each
meeting, any public visitors are invited to share comments and
concerns.
In addition, one can:

Submit suggested report topics to Committee staff

Assist in the planning of Committee meetings and site
visits, especially if the Committee is meeting in one’s
state

Submit nominations for Committee membership
http://ruralcommittee.hrsa.gov

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