National Forum of State Nursing Workforce Centers Denver, Colorado June 12, 2015 Federal and State Policy Perspectives: Focusing and Targeting Collaborations.

National Forum of State Nursing Workforce CentersDenver, Colorado June 12, 2015

Federal and State Policy Perspectives: Focusing and Targeting Collaborations to Achieve Impact

Sheila P. Burke, RN, MPA, FAAN

Harvard University

Baker, Donelson, Bearman, Caldwell & Berkowitz, PC

2

Unique Features of U.S. Health Policy Making

• Very frequent elections

• Weak government executive branch at all levels

• Strong difference in values between political parties

• Strong role for major private interest groups

• Strong role for public opinion

3

Congress and Health

• Deeply divided electorate on the role of government

• Deep partisan differences on government health care programs

• Congress plays a major role in development of health policy

• Authority spread across several committees

• Involvement includes regulatory, programmatic, financing, and oversight

4

• Enactment of Medicare and Medicaid (1965)

• Employee Retirement Income Security Act (1974)

• Americans with Disabilities Act (1990)

• Family Medical Leave Act (1993)

• Temporary Assistance for Needy Families (1996)

• Health Insurance Portability Accountability Act (1996)

• State Children’s Health Insurance Program (1997)

• Medicare Modernization Act (2003)

• Affordable Care Act (2010)

Examples of Congressional Legislation in Health Policy

5

Mary Eliza MahoneyNew England Hospital for Women and Children’s

Nursing School, 1879

6

• Improving the patient and provider experience of care• Improving the health of populations• Reducing per capita cost of health care

Triple Aim

7

Major Components of Federal Expenditures% of GDP 2011-2051

Source: Congressional Budget Office.

Social Security

Other Mandatory Spending

Healthcare

Discretionary Spending

0%

2%

4%

6%

8%

10%

12%

14%

2011 2021 2031 2041 2051

% of GDP

WWW.BIPARTISANPOLICY.ORG

17

8

Federal Spending Projected for 2024

Health Programs” includes: Health insurance subsidies, exchanges, and related spending; Department of Defense Medicare-Eligible Retiree Health Care Fund (including TRICARE for Life); Children’s Health Insurance Program, and other programs.

Medicare(15%)

Medicare(15%)

Defense(12%)

Defense(12%)

Medicaid(10%)

Medicaid(10%)

Social Security(26%)

Social Security(26%)

Other Mandatory Spending

(7%)

Domestic Discretionary

(11%)

Agriculture (0.3%)

Other Mandatory Spending

(7%)

Domestic Discretionary

(11%)

Agriculture (0.3%)

NetInterest(15%)

NetInterest(15%)

Other Health Programs(3%)Other Health Programs(3%)

Source: The Congressional Budget Office. The Budget and Economic Outlook: Fiscal Years 2014 to 2024, February 2014.

11

9

Note: * Estimate. Expenditures shown in $US PPP (purchasing power parity).Source: Calculated by The Commonwealth Fund based on 2007 International Health Policy Survey; 2008 International Health Policy Survey of Sicker Adults; 2009 International Health Policy Survey of Primary Care Physicians; Commonwealth Fund Commission on a High Performance Health System National Scorecard; and Organization for Economic Cooperation and Development, OECD Health Data, 2009 (Paris: OECD, Nov. 2009).

    AUS CAN GER NETH NZ UK US

OVERALL RANKING (2010) 3 6 4 1 5 2 7

Quality Care 4 7 5 2 1 3 6

Effective Care 2 7 6 3 5 1 4

Safe Care 6 5 3 1 4 2 7

Coordinated Care 4 5 7 2 1 3 6

Patient-Centered Care 2 5 3 6 1 7 4

Access 6.5 5 3 1 4 2 6.5

Cost-Related Problem 6 3.5 3.5 2 5 1 7

Timeliness of Care 6 7 2 1 3 4 5

Efficiency 2 6 5 3 4 1 7

Equity 4 5 3 1 6 2 7

Long, Healthy, Productive Lives 1 2 3 4 5 6 7

Health Expenditures/Capita, 2007 $3,357 $3,895 $3,588 $3,837* $2,454 $2,992 $7,290

Country Rankings

1.00–2.33

2.34–4.66

4.67–7.00

Overall Ranking

7.2 7.0 6.9 6.8 7.0 6.8 6.8

10.311.1

10.2 9.9 9.9 9.610.1

5.3 5.1 5.0 4.9 4.8 4.7 4.7

0

4

8

12

1998 1999 2000 2001 2002 2003 2004

U.S. average Bottom 10% states Top 10% states

National Average and State Distribution International Comparison, 2004

2.8 2.8 3.1 3.2 3.3

4.4

5.3

6.8

Japan

Iceland

Sweden

Norway

Finland

Denmark

CanadaU.S.

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008.

Infant Mortality Rates, 2004

Infant deaths per 1,000 live births

Data: National and state—National Vital Statistics System, Linked Birth and Infant Death Data (AHRQ 2003, 2004, 2005, 2006, 2007a); international comparison—OECD Health Data 2007, Version 10/2007.

11

Projected Age Distribution

12

What Do You Think is the Most Important Problem Facing this Country Today?

CBS News/New York Times Poll. April 30-May 3, 2015. N=1,027 adults nationwide. Margin of error ± 3.

      %  The economy, jobs 20  Misc. social issues 7  Racism, race relations 5  Misc. government issues 4  Income gap/disparity 4  Immigration, illegal immigrants 3  Barack Obama, the president 3  Religious values, school prayer 3  Police problems, corruption 3  Other (vol.) 44  Unsure/No answer 4

13

Most No Paying Close Attention to Coverage of King v. Burwell

14

Examples of Congressional Legislation in Health Policy

• Harvard presentation

15

Believe Responsibility of the Federal Government to Make Sure All Americans Have Health Care

% saying yes, is federal government’s responsibility

Democrat

Republican

71%

20%

Gallup poll, November 2011

16

Concern about Government Involvement in Health Care, by Party

% saying they are concerned about the government becoming too involved in health care

Democrat

Republican

37%

88%

Pew poll, June 2012

17

A New Era in Health & Health Care

18

Florence Nightingale

19

Civil War Nurses

20

Spectrum of provider payment: reform trajectory moving towards global payment

Current payment for

units of service

Add pay for performance

Subtract payment for preventable

complications

Mixed payment (patient-centered medical home)

Episode-based

(bundled) payment

Global payment

21

Research

22

Improving Quality and Reducing Costs – Center for Medicare and Medicaid Innovation (CMMI)

• Accountable care organizations (ACOs)

• Chronic disease management

• Patient-centered medical homes

• Health Information Technology (HIT)

• Quality reporting

• Duals demonstrations

23

2015 Policy Discussion: Key Issues Bubbling Up

Coverage of those in states not expanding

Medicaid

Affordability of premiums and cost-sharing

Narrow networks

Coverage of undocumented

immigrants

Churn

Individual mandate

Employer mandate

Court challenge to subsidies in

federal marketplaces

Workforce shortage Funding of

research

Big Data

Privacy

Chronic Illness

Delivery system reform

24

Next Steps

• Start at Home

• Find a Mentor

• Learn by Doing

• Ask the Tough Question

• Be Informed

• Volunteer

25

Rules

• Bring the evidence to the table

• In presenting data, be short and to the point

• Narratives that put a human face on an issue have an enormous impact

• Timing / Windows of Opportunity

• The importance of building bridges and finding partners/advocates

• Don’t burn bridges

• Know what you Know and Don’t Know

• Know your audience!

26

Conclusion