National Forum of State Nursing Workforce Centers Denver, 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 Mahoney New 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 Source: Congressional Budget Office. Social Security Other Mandatory Spending Healthcare Discretionary Spending 0% 2% 4% 6% 8% 10% 12% 14% % of GDP 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%) Net Interest (15%) Net Interest (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

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). AUSCANGERNETHNZUKUS OVERALL RANKING (2010) Quality Care Effective Care Safe Care Coordinated Care Patient-Centered Care Access Cost-Related Problem Timeliness of Care Efficiency Equity Long, Healthy, Productive Lives Health Expenditures/Capita, 2007$3,357$3,895$3,588$3,837*$2,454$2,992$7,290 Country Rankings 1.00– – –7.00 Overall Ranking

National Average and State Distribution International Comparison, 2004 Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 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, N=1,027 adults nationwide. Margin of error ± 3. % The economy, jobs20 Misc. social issues7 Racism, race relations5 Misc. government issues4 Income gap/disparity4 Immigration, illegal immigrants3 Barack Obama, the president3 Religious values, school prayer3 Police problems, corruption3 Other (vol.)44 Unsure/No answer4

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

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