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 Evan S. Dillard Dr. Joellen Edwards Dr. Michael Enright Bessie Freeman-Watson Joseph D. GallegosJulia Hayes Dr. Len KayeMichael Meit Arlene Jackson MontgomeryRon L. Nelson Sister Janice Otis The Honorable Larry Otis Dr. Patti J. PattersonSenator Raymond Rawson Dr. Thomas C. RickettHeather Reed 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 well-being 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

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

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. BETTER SERVE THE CLIENT2. Efficient use of resources3. Creating a link between collaboration and

broad goals of the community4. 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: 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

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

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 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: 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

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.)

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: 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

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

Rural Americans have higher incidence of obesity than urban counterparts

Obesity is now more common in rural, low-income populations

Cultural influences in rural areas often contribute to obesity

Rural Obesity: What We KnowIncrease in Overweight and Obesity Prevalence Among U.S. Adults* by Racial / Ethnic Group

Overweight (BMI > 25)

Prevalence (%)

Obesity (BMI > 30)

Prevalence (%)

Racial / Ethnic Group 1988 to 1994 1999 to 2000 1988 to 1994 1999 to 2000

Black (non-Hispanic) 62.5 69.6 30.2 39.9

Mexican American 67.4 73.4 28.4 34.4

White (non-Hispanic) 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: 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

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

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.)

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

Although much authority now in the hands of the States, national requirements were set on States and welfare participants: 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 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 povertyHigher unemploymentLower education levelsLess 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

TANF recipients often face many barriers to moving into the workforce and off of welfare: 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 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

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 low-income families

The National Advisory Committee on Rural Health and Human Services

Topics for the 2006 Report

1. Access to Pharmaceuticals in Rural Areas

2. Health Information Technology in Rural Areas

3. 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