A Senior Vice President with the center, and have the distinct pleasure of working with and overseeing our health care project. We have a very full agenda. Let me get a few logistics out of the way quickly. To this newdjusting way of conducting meetings and events. We hope everything works out as it goes through and think the Production Company for helping us put this on. For those of you who have joined , you willplatform receive a message shortly from bailey,ur staff, morgan in the chat box function with a link to the report. For the viewers, the cspan viewers and others who wish to get a copy of the report, you can go to our website bipartisanpolicy daughter, and a eventsll be on the bpc page under the health section. Later this morning, you will have an opportunity to submit your questions to our Task Force Members vie the q and a function at the bottom of your screen. To the purpose of this event, personally coming from a rural area of indiana with our family farm still operational, this is a personal issue with me. Over 126 hospitals have closed since 2010. An estimated new the 560 hospitals were at risk of closing, even before covid19 outbreak. Dr. Susan turney is the chief executive of the Marshfield ClinicHealth System in wisconsin. A system that we work with at bpc. Recently was quoted the Rural Health Care was in a crisis before this pandemic, and that funding to stabilize systems today is critical so we can continue to survive. We are hopeful an agreement can be reached in congress, even in the senate, and maybe later today. That will add additional funding to our Hospital Systems that are so in dire need of assistance. Particularly those in rural areas at the outset, we would like to thank the Helmsley Charitable trust for its work we have done with the rural task force. We watched this project over a year ago. Long before covid19 was an issue. We believe many of the recommendations today can help stabilize rural hospitals during this Current Crisis and better support the Rural Health Care system post crisis. Cochaired and was olivia snow, he will hear from. Along with two other cochairs, former governor Ronnie Musgrove of mississippi, and Tommy Thompson of wisconsin. The bp staff and Task Force Members visited rural hospitals in New Hampshire and iowa, maine, tennessee, vermont, even wisconsin. Analso have the insights of honorary Bipartisan Congressional Task force on Rural Health Care, including senators Chuck Grassley of iowa, cana smith of minnesota, bill cassidy of louisiana, angus king of maine, congressman Jodey Arrington of texas, and congresswoman taurus small of new mexico. Senator grassley has not been able to join us this morning, but has given me a statement to read. That will be followed by a video from congresswoman small, and one from senator cassidy. Before i turn it over to the director of the Health Project for discussion with members of the task force. Statement. Ssleys as a Solutions Oriented organization, the Bipartisan Policy Center has the leadership bench from which to help shape the Rural Health Care debate. I welcome and encourage the bpc advocacy efforts that bring a range of policy options to the table. As chairman of the Senate Finance committee, i have in working over the past year to develop a targeted set of commonsense medicare payment policies that help isolate Rural Communities provide reasonable access and needed medical care as close to home as possible. I will continue leveraging my leadership positions to champion innovative, costeffective, and highquality Rural Health Care policy solutions. I will review the policy options released today carefully. It is my hope that these recommendations will spur more dialogue among the unique challenges facing our Rural Health Care delivery system. Lawmakersportant as develop Meaningful Solutions and Work Together to have a bipartisan path forward. Cross Party Coalitions are the best way to turn targeted Rural Health Care solutions into law. I ask them to work with me to help build that kind of Bipartisan Coalition as i work on formulating policies that will get more lawmakers on board in washington. The Rural Health Care matters. Many Rural Communities are struggling to Keep Health CareServices Available to their residents. This is especially true with the pressures of the ongoing nationwide fight covid19. The sacrifices and efforts to stop the virus have shut down the u. S. Economy and life as we know it this virus has and will continue to invade small towns and big cities. One thing we can count on is our rural hospitals and providers are standing guard on the front lines ready to care for the People Living in their own communities. Even as the devastating effects of the Public Health emergency deal a blow to the economy and exhaust health care professionals, communities banding together to help neighbors in need in ways big and small. Americas entrepreneurs, medical scholars, innovators, data scientists, and captains of industry are collaborating to our civic organizations, economic institutions, and all levels of government to stop the spread, save lives, and solve albums. We need to harness that same energy to make sure rural providers are equipped to address the unique temperature needs of immunities now and in the future. Togetherin and pulling the resilience of the american spirit will guide us to better days ahead. Senator grassleys statement. At this time, we will have a video from congresswoman taurus small from new mexico. I guess it is grassley. Thank you for joining the bipartisan policy for this first so a virtual event. The Task Force Report and policy recommendation. Communities across the country are facing unprecedented time. We are having this fight to keep families safe and their lives together. All of america is hurting right now. Many Rural Communities are hurting. The start of the Public Health emergency, i have fought for emergency funding for Rural Health Care facilities, expanding telehealth in our rural areas, and protecting the Rural Health Care world. Ive also join my colleagues on both sides of the aisle and demand federal accountability to our Rural Community and calls for the administration to establish a rural covid19 task force. This Public Health crisis only heightens the need for bipartisan collaboration with a solution. As we continue to fight the spread of covid19, partisan politics aside and with the party line, pass legislation to our Rural Community. Covid19 has also shown the importance of continuing this work, even after our community prices. Challenges like access to food, reliable broadband, Health Care Must be addressed to ensure we are saving families no matter where they live i introduced isolation to incentivize medical professionals and expand teleHealth Services. The fight for rural families will continue. The Bipartisan Policy Center preimposes on Rural Communities with the creation of the world health task force. Recommendations are critical for any policy. Core health care and deliver solutions. Thank you for joining the bipartisan policy today. I look forward to working with many of you in the future. Was senator cassidy appearing instead of congresswoman torres. We are all learning this new technology. Hopefully we can work out some of these bugs. Now could we try to have senator cassidys video cued up . Bill cassidy here, a doctor, but also u. S. My medical practice i used to work in a hospital. That included many that had to come from our away from Rural Communities. Then i realized these folks have transportation. A lot of folks in Rural Communities relying on others just to say they may or may not have transportation. Challenges,f the but how do we improve access and care to those in Rural Communities . This has been highlighted by the Novel Coronavirus epidemic. Although right now, the Rural Communities have been relatively unscathed, i saw an article in the New York Times in which we begin to see increasing numbers of cases in the Rural Communities. Preserveenge is how to increased access, improve care in Rural Communities. The future is now. Those communities struggle. Whether or not you are in the Rural Community. Health care is too high. Deductibles on these change plans are extremely high. The cost of medications are very high. If you look at diabetes in the rural areas, more of them are going to be diabetic. The cost of insulin will be a particular problem. Recruito difficult to providers to rural areas. Of aconomic Fortune Community decline, there is appeal to a spouse. They have another career where they work if there is an economic decline, which means your workforce gets older. Kids grow up and move away. Have more, you economic decline, because you dont have a young doctor to attract a family with the assurance of good health care. You need to reverse that somehow. Statistically, those in rural areas are older, not just the workforce, but everybody. A little bit older and more chronic disease. So we have a challenge. How to preserve access to health care in rural areas, improve it to raise it up. What are we attempting to do . The Novel Coronavirus epidemic is doing a lot of tragedy. It has disrupted our economy. There might be good things that come out of it. Expanding the use of telehealth. That is wise. Now a provider can communicate with the person across town, across the state, and deliver services. We had that capability before in rural areas because of the need to implement this. They are going to scale. Going to scale would be beneficial. We are making more use of home. Evaluate them. D telehealth,d use of it may be physically seeing the patients, but they can monitor Blood Pressure with a Blood Pressure cuff, or oxygen. Those at home 100 miles away from the doctor that have to see if there is an issue consent home health to the home and have the condition addressed and the patient never needs to come in. If a patient in a rural area for transportation, maybe they did not have transportation, we kind of eliminate that as an issue of expanded use of remote monitoring, telehealth,. Arer this current law, we allowing standard use of telehealth. Something have to be with a videoconference, it can be a smart phone in which somebody speaks to the doctor this way, and it is communicated on the smartphone. That may or may not stay in place after the coronavirus, but i think we are becoming more innovative on how to use current technology. Atre is a special need maternal health. They cannot be as good for those women delivering children. We have to address that is a special case. Theres a lot of effort to do that. Im sponsoring some of that in federal legislation. Continued by a variety of circumstances to attempt to preserve our health care in the rural area and improve. One thing we do is draw the attention of leaders and policymakers and those who impose policymakers. So i think you for your leadership. We also have to exploit. We have to understand in a way which unless you have in there, you may not understand. We have to understand someone who lives 50 miles away from the call that is 40 years old may not be able to get to the doctor. That fundamental lack of understanding, the circumstances of a poor persons life who of what werural area are attempting to do. We have to come up with novel financing plans. Theres been a lot of attempts. Example, through the Affordable Care act organizations to reduce the calls for a person. Those folks are in the rural area. They should be sharing with the rural hospitals. You need to preserve the rural hospital so the patient has a place to go if there is an emergency. A place to go to get labs done. It also provides employment for the economy. Did i say she doesnt have good access . This brings the care closer to her. The mission of the rural hospital is there still needs to be sharing through financial policies. Decreased, benefits and allows to keep the doors open. I think there has to be ways of delivering health care. Involve Public Health. Forhousand children hepatitis b. We bring vaccinations to the classroom. No cost to the parents and teachers. Vaccinated the children at school. We brought the health care to the student. We have to think of other ways to bring the mobile unit. So that the person drives 50 must to get the mammogram, she can have it through a mobile unit. I think you have the concept. I thank you. Our usual goal is to improve access, approach health care in the rural areas. It is important for the patients , important for the economics in the rural area. If theres one thing the coronavirus taught us, we are in it together. I would also add it acknowledges we are in it together. Thank you. Mailing, it is up to you. Good morning, everyone. For joining us. I would like to introduce our panel who is going to help us understand what in the report. We will go over the highlights of the report area the five analyst with us are members of the task force. We have two of our cochairs with us. Majority leader tom daschle. Also a cofounder of the bpc. We have senator olivia snow of maine, who is also a cochair of the task force. Shes also a senior fellow and board member at the bpc. Former congressman tom hockey of iowa with us. Also chris jennings, founder and president of jennings policy strategies. You will also remember he was in the clinton and obama white houses working on health care,. He is a senior fellow at bpc. Belinsky,ve gail senior fellow at project health. A former administrator of the Health Care Financing administration, which we now know as the centers for medicare and medicaid services. Repeat a couple of the housekeeping points he went over. Question at any time during this event, you may go ahead and ask. You will click on the q and a feature and submit your question. I will go ahead and ask the panelists as many questions as we have time for. You will also notice there is a chat function in zoom. On chat, you will not be speaking with one another , but what you can use chat for is to receive information from us at the bpc. For example, our staff has posted the link to our report. Report. If you would like to see the link for a report, open chat, you will see the url for that and see the report. The other thing i wanted to tell you is you have either gotten into zoom, but the other way to watch this webinar is through youtube. The way to do that is to go to bpcs website. Bipartisanpolicy. Org. Click on events, and you will see a link to watch this. At this time, i will turn it over to our Task Force Members who will go through the highlights of our report. We will start with senator daschle. Thank you very much. Announced the release of our recommendations on the Rural Health Task force. For the last year, my colleagues and i have worked to find Common Ground to stabilize and improve the challenges facing Rural Communities. Stress ofe the covid19, these problems were urgent. As a senator representing south dakota. The long understood population is older. The people in north america are less likely to have insurance. As covid19 spreads across the country, a situation for Rural Communities is more dire than ever before. Nationsh dakota is the number one hotspot for the coronavirus. Because of the latest outbreak. And it shows how fragile the Rural Health Care system really is. More than 100 rural hospitals have closed since 2010. Today, nearly 600 are at risk of closing. That leaves people in rural areas with no choice but to drive long distances to get the health care they need. Too often, they simply forgo that care completely. Add covid19 to the mix, and struggling rural hospitals are now desperate. The coronavirus has significant financial has caused significant financial pressures to these hospitals. Many of which are laying off and furloughing employees. Some are laying off as much as half of their entire staff. Governor hospitals around the country postponed elective procedures. While some hospitals can absorb the financial impact, many rural hospitals dont have Profit Margins that would allow that. Congress has responded to covid19 with legislation and regulation, but has opened the doors in new ways for patients to receive care. Some clinicians breaking down partners barriers to help with telehealth in particular. Many of these measures are temporary. Covid19 will eventually end the need for telehealth and Rural Services. We will see an even greater reliance on these approaches as time goes forward. In iowa, site visits New Hampshire, maine, wisconsin, tennessee, and vermont, and numerous interviews with rural Health Experts and stakeholders, our task force is releasing policy recommendations that will hospitalslize rural in the short term and create pathways to transform over the longterm. To transform in ways that meet the changing needs of Rural Communities, we are also recommending policy changes to make it easier for rural providers to move to valuebased care and encourage clinicians to come to rural areas and stay there. To stop the wave of unit closures and improve access to care by breaking down barriers to those teleHealth Services. Im going to turn it over to olivia, one of my fellow task force cochairs. Two of our other cultures couldnt be with us today. Been veryave invaluable as we have continued our work. With that, olivia. Thank you. I certainly appreciate the opportunity to join other members of the task force. I also want to show my appreciation to the Bipartisan Policy Center and Helmsley Charitable cross for making this task force possible in the first place at such a critical and timely issue, especially now in the midst of this pandemic. Maine, i amesented familiar with all of the issues surrounding the challenges confronting rural hospitals and rural clinics, and Rural Services in Rural Communities. Im pleased to be a part of this initiative. I will focus on the recommendations in our task force regarding the substantial number of rural hospital closures over the last decade. And we know the financial pressures that have been result of the a covid19 crisis. Address a number of these issues that we think are important to the sustainability of rural facilities. Traditionally, care has been centered in inpatient hospital settings. Care inients receive both Community Settings and outpatient. That has contributed to a significant decline in hospital revenue. To enable communities in rural facilities to transition to a model that makes sense, and we recognize in the task force that the community has different needs. So we decided first and foremost to develop recommendations to stabilize rural hospitals and rural clinics. First by providing immediate Financial Relief over the. We think that is a timeframe that is essential or communities to make the transition to transformation models congress can do this first by providing immediate Financial Relief from a 2 reduction in medic as well as relief from medicare debt payment reductions. Package,ergency Relief Congress included a temporary suspension of the cuts through the end of 2020. That congresse should increase financial assistance, in terms of reimbursement. Currently, these hospitals cosive about 101 of their ts. We consider the sequestration cuts that have occurred as 99 of their costs being reimbursed. Obviously they dont break even. Providing a 3 increase in conjunction with the medicare sequester relief, that would be a net reimbursement. It would be about 104 of their costs. Ofhappen to think this level funding would enable them to remain operating and at the same time build and invest in stronger Health Care Services. These measures are temporary. As i said, intended to stabilize rural hospitals and rural clinics as they determine the best pathway forward. We also propose in our Task Force Report establishing pathways for transformation. So that these measures are flexible in that we include various payment models that will fit the needle pacific communities. For those who want to make this transformation possible, for communities and Rural Communities, they need to commit a hospital transportation Transformation Plan. That assessment is similar to the assessment currently conducted by rural hospitals. It would also include input from all of the stakeholders in a particular community to ensure the Transformation Plan reflects the need of that community. One of the first models we proposed is called the rural emergency hustle designation. Allow rural hospitals to transform from an inpatient hospital facility to one that provides outpatient Emergency Services, or other services, such as extended care services. We also include several payment models. One that would include 110 costbased reimbursement. The third is the medicare outpatient prospective Payment System. Either combined with a grant for other services, or based on pair member, per visit, and predicated on the number anticipated in a specific community. Another model that we proposed is the extended Rural Services. Under this model, it would allow rural hospitals that either closed or no longer provide certain services, we can talk to several qualified Health Centers, Health Clinics from adding these services and being paid for them so they are no longer available in the hospital. Such as urgent care or Emergency Services. We also call upon the center for medicare and Medicaid Innovation to develop proposals that would call together multiple pairs and providers based on the global budget and model, similar to the global payment model currently being tested in the state of pennsylvania. We also are calling upon the center to promote models for the integration of Rural Health Care clinics, as well as rural hospitals. With that, i will turn it over to my college to talk about the transformation of clinician payments. Thank you very much. I am going to be focusing on clinician payments and maternal care. We are seeing the country move towards valuebased care. This has been much harder and forward in rural areas. Some of the reporting requirements can overwhelm smaller banks. Lower volume of services there means there are fewer to spread the overhead costs over. It makes it difficult for rural providers to take on financial risks. Our task force has recommended a number of technical to the current Payment System to enable more of the patient centered care, including eliminating insurance and services. We suggested using readily available medicare claims data to reduce the Administrative Burden of quality reporting. Ultimately, medicares Innovation Center will need to increase access to payment demonstrations that are flexible enough to meet the needs of Rural Communities. Our task force has made several important recommendations to improve maternal care in rural areas. Mortality,d infant unfortunately, has been increasing across the country. The rates are higher in rural areas. This has been caused by lack of access to local eccentric services. 2004 and 2014,rs for example, 9 of rural hospitals closed their obstetric without anyg half hospitalbased maternal care at all. One study found the loss of the service resulted in an increase in preterm births and births that occurred outside of the hospital. To make sure women can receive adequate natal care and continue being able to deliver their babies locally, the Task Force Recommends increasing the reimbursement of cedric services. Medicaid covers more than half of the deliveries. And there is a lot of variation in state payment rates. Many of the rural hospitals n. Ent even breaking eve the secretary of dhs should be able to reimburse rural for care in the Health Professional service area. And the National Median commercial rate. We also recommend congress increases funding for education or Training Programs to make sure primary care clinicians will have the necessary skills to deliver prenatal care and other maternal services. I will turn this over to chris jennings, who will talk about our workforce recommendations. Thank you. It is certainly no secret that rural areas face Significant HealthCare Workforce shortages, both for primary care clinicians and specialists. Hasill be an old movie that the same ending if we dont more effectively highlight problems, produce new and viable policies, and make a compelling case toward change and effective implementation. Lets start with the compelling problems. It is undeniable that we have a Rural Health Primary Care shortfall. Without action, it will clearly get worse before it gets better. Have only 40 primary care physicians for every 100,000 people. That compares with 53 in urban areas. That gap is so much greater for specialists. Rural areas have 30 specialists for every 100,000 people, compared to 263 specialists in urban areas. Address manyand to of the issues members and bill have raised, that disparity is much worse when it comes to access considerations related to the longdistances between providers and patients. To make matters worse, nearly one third of primary care providers in rural areas are over the age of 56 and nearing retirement. Worseicture may be even than it appears when it comes to primary care shortages, because it appears in Nurse Practitioners and physician assistants are classified as primary care clinicians, even when practicing as specialists. Amongst our first recommendations was to make sure we have a clear line of sight into the problem by recommending the Health Services and Service Administration assign a specific special classification to have a more accurate assessment of the problem we face. Anwe do that, we recommend independent review. Orwill suggest by either eao the National County of sciences of all rural workforce programs within hersa to determine which programs are effective, which should be prioritized, amended. But the task force clearly was not satisfied on waiting for another review when we face a rural Health Crisis now. If you know these numbers, that shouldnt surprise you. We strongly believe you cant expect the same policy to deliver new results. Because of our experience in this area, the task force acts concluded we know enough to make new recommendations and take some bold actions. We are recommending incentives that would both encourage clinicians who moved to rural and alsostay there, make greater use of the existing workforce. First a Task Force Recommends providing federal tax credits to clinicians who practice in rural areas. This is not being done now. Incentives such as loan forgiveness programs already bring some clinicians into rural areas, keeping them there has really been a challenge. Tax credits in two states, oregon and new mexico, have already proven effective for retention. One of the most difficult objectives any community faces. Ishough the state experience encouraging, we believe a limited number of state and the inadequacy of the tax credits are suppressing the potential for this policy. In the current covid19 environment, states simply will not have the ability to lose even more revenue through tax credits at the very time they are losing all of this revenue coming into the coffers. Assets we recommend as an example of tripling the value of these credits and escalating amounts over three years. Recommendsrce also that we notably expand the number of j1 visas from the conrad 30 to 50. These allow International Medical graduates to stay in the u. S. An additional three years to practice in shortage areas. Third, the task force embraces the importance of making greater use of the existing workforce. We recommended the hhs secretary assess the impact of the reimbursement to Health Care Providers that it currently doesnt cover, such as pharmacists and social workers. We also believe if a strong case could be made, the effective use of these providers could enhance the overall value and medical outcome of the patients they serve. Also, there is a documented urgent need for additional behavioral Health Care Services. We know that in particular through the isolation issues that many of us are aware of. Medicare does not cover marriage and family therapists, and licensed Mental Health care counselors. This is a case even though they are included in the Public Health service act and may be called into service by the national Health Service corps. We be called into service by the national Health Service corps. Medicare should step up and cover these providers. We have more recommendations in this area that i encourage you to review. But for my last duty come i reflect on the past. 30 years ago to this year i had the privilege of staffing the socalled pepper commission. Congressman tom cocky was even then a compelling advocate to addressing the unique challenges of Rural Health Care in new and innovative ways. It is my pleasure to turn it over to the congressman to discuss our recommendations on telehealth. Thank you very much. Great toit has been work again with you and all the members of the task force. Some 30 years ago when and issman Mike Steinert cofounded the Rural Health Caucus in the house, we believed that technology was the key to delivering Health Care Services to Rural America. Dream ands just a today it is becoming a reality. Health i. T. Ce sees as essential to expanding access to care in rural areas. Hasresponse to covid19 focused on getting care to people who cannot see their doctors facetoface. This is an everyday problem. Before covid19 and will be after in rural areas. Where people have live long distances from medical care. Hasr the threat of covid19 passed, rural residents will continue to need telehealth and other virtual technologies. One good thing emerging from the covid19 epidemic is that congress and the trump waived manyon medicare restrictions for telehealth. Using restrictions around the site of service and allowing telehealth for patients not already established with a clinician. There is also new flexibilities allowing phone calls and other nonvisual visits to be paid for. Congress has temporarily allowed a patients home to be an originating telehealth site and this is very important. These changes make sense. Telehealth to making a real option for Rural Americans. Come all of these changes, could should be permanent and not require a waiver. Hcsl Health Clinics and fq should be permanently allowed as distant telehealth sites. These changes that have been made in response to covid19 are consistent with the Task Force Recommendations so we have been pleased to see them implemented. In addition to these changes, Congress Also should allow clinicians to provide services to Medicare Beneficiaries across state borders and eligibility of should be Services Based on where the provider is located in of where the patient is located. Come a clinician must get a separate license in each state where he or she is providing teleHealth Services which can limit the ability of providers to offer care to Rural Communities. Us with aas provided valuable experience to see how well some of these changes are working and how we can use them after this pandemic. They have demonstrated that telehealth can function well, very well in connecting patients and their clinicians. These changeske permanent and build upon them. Finally, the Task Force Recommends expanding access to broadband in rural areas. Toolband is the essential for providing high quality teleHealth Services. Yet about a quarter of Rural Americans and a third of those on tribal lands do not have access to adequate broadband. Colleagues and i have explained the highlights of our task forces recommendations. Let you know where you can find our report and the rest of our recommendations. Fantastic. Thank you to all of the members of the task force. If you are looking for the functionpen the chat in zoom and you will see a link to the report there. If you would like to ask a question, open up the q a andion, the q a cap in zoom you will be able to send a question in. I will see the questions. I will ask as many of the questions to the panel as time permits. With the real elephant in the room and that is covid19. As bill mentioned when we first started working as a task force, we were not thinking about covid19 but now it is a reality affect all corners of our country. And including in a big way rural areas. Chris, i wanted to ask you if you could talk a little bit expect we can there may be a covid relief package in the senate today. We know that already there has been 100 billion legislated for hospitals. There was no indication in that legislation for how that would be split up. I would love to hear from all the Task Force Members about what we do need. We have been hearing from a rural hospitals and all hospitals everywhere that this is not enough. For the rural hospitals that have had to put a pause on their elective procedures and this is where they make their money, they are really having a lot of trouble and we are hearing from some of these hospitals that have already been struggling with less than a weeks worth of cash on hand and now they are losing millions of dollars that they are potentially going to have to consider cutting back services or folding altogether. Chris, can you kick us off . Tell us what we can potentially see in the senate today. What additional help we could see . I would love to have the other panelists jump in with their thoughts. it is a pleasure. As most of these members of congress can attest, when you have moments like this, much and in tentse over period of time and you are digging out what you just passed occasionally and we are reading through that now. Last night, there was an agreement for another 450 billion for covid19 related activities. 100 billion dollars of that 450 billion will be dedicated for Additional Health care investments. 75 billion for hospitals. And there is some initial reporting that a significant portion, probably that means a little more than a disproportionate portion of that may be going to rural areas. There is a lot of members who are extremely concerned about the infrastructure challenges and service challenges that this disease poses on their communities. We are seeing that being raised in a host of other areas as well and that gets applied, for example, to testing as well. Testing capacity. Testing distribution. There continues to be a debate among republicans and democrats in the administration on how best to allocate this testing, how to ensure capacity, how to distribute it with the democrats hoping for a little bit more and theleadership president indicating a little more comfort with relying on local and state communities to make some decisions. So, all of which to say yes, you mentioned 100 billion for providers last round and this is another 100 billion of health care. There is almost inevitably going 4. 0be a big push for a version. This is being called 3. 5. I anticipate that to begin with and hours. This is expected to be passed this afternoon with the house passing soon after. We need to watch and dig through for allocations and formulas. I get other members of our panel to way you and if they in if you to weigh would like . Do we what makes sense what is the proportion of funding . We need to understand that hospitals were struggling before this. Time18, that was the first that hospitals were seeking positive operating margins after several years of not having that happen. And so, there is not a lot of resiliency for many hospitals. Rural hospitals have had even more challenges. But this has been a pretty challenging time in general. Covidrecognizing that the crisis is coming on what had already been it fiscally stressed time. When we talk about testing, i think we have to be smart about how we approach it. How it to think about manages sampling to give us a hint of those areas where there needs to be aggressive involvement in those areas where you may be able to have more selective involvement. Term is no way in the near we are going to have enough Testing Available for 100 of the 330 million of us to get tested nor should that be necessary. But you do want to go to the areas in the populations that are most at risk. Do testing there. And let that guide us as to whether or not you need to do more testing in an area or whether you can move on. There is some notion on how sampling can help so we can use these resources in a smart way. Gailllowing up on what said, many of the rural hospitals were in financial trouble already. The covid19 virus has exacerbated the problem in so caused manys facilities not to engage in routine activities such as elective surgeries and as a result, their revenue is going down as a result of covid19. The aid from the federal government to these rural hospitals is it really important in order for these hospitals to be able to survive and it is justified because of the fact that it is Government Policies that have resulted in this temporary reduction in the systems to rural hospitals. I dont know what is in the bill related to telehealth. I certainly hope there is also some Financial Support for the advancement of the kinds of in thei talked about report related to telehealth. For deliveringue the services and ensuring there is reimbursement for those services that are delivered via telehealth and that is very critical. I would add it has been summed up well. Will go in multiple stages. It is really important for congress to relate get a handle to really get a handle on the problem that exists most especially in rural hospitals. Indicated director that there are spikes in rural parts of maine and in other parts of the country. They are already facing the enormity of financial problems and this is magnified in that. It is important that congress understands exactly what is the breath of the problem that exists for hospitals at multiple levels. As has been mentioned, many of the hospitals have had to forgo elective surgeries, not receiving any revenue. I know some of the hospitals here in maine have already hed employees and reduced salaries. It is becoming a greater challenge. I think it will be important for those of us that are on the front lines for this report but also for hospitals to be able to communicate to their elected officials exactly what is transpiring. There is an immediacy to the problem but also because cascading effect it is having on hospitals that are already under great financial constraints. If i could pick up on what olympia just said it is important for us to keep our focus on the short term and dealing with the crisis as it continues to expand throughout rural areas. That is first and foremost. I think we have to do it with an eye to the longerterm as well. Crisis willcovid19 end or at least diminish and circumstancesave involving the infrastructure that we will have to address. It is important for us to think about it in four buckets. Resources. We talked about the need for resources in a series of different capacities. Resources are critical including increasing the reimbursement for critical access hospitals and finding ways to deal with the sequestration issue that could take effect next year. There are a number of things that we have to look at in addition to telehealth that will require more resources. The second bucket is regulatory. After figure out ways to ensure that there is more regulatory flexibility for hospitals and providers. That regulatory relief and flexibility and pragmatic approach as we look at applications in Rural America is really essential. The third is workforce. We have to understand that the workforce in Rural America in particular is continuing to become even greater a far greater problem. Scope of practice issues. The national Health Service corps. Ourother ways to augment workforce is really going to be critical. And telemedicine plays into that. Bucket is a final recognition of the need for a transformation away from the way we look at health care, the financing in the past, valuebased and social determinatebased approaches to Health Care Going forward. All four of the buckets will be critical in the short term but also the longterm. Ok, senator, thank you. Getting back to you about telehealth. You laid out what has already happened and the progress you have made in a short period of time. One of the questioners is asking. Bout the emphasis on medicare a lot of what we are talking about really is coming through medicare and yet we have a lot of people in this country in commerciald in insurance or commercial coverage. How does all of this apply to them . Inould love others to jump as well but will they be able to take advantage of some of this progress . What more do we need to do there . Regulations are so important. Issuesf the regulatory and payment issues relating to medicare have been addressed and permit telehealth. Depending on the state, there are other issues related to payment that affect Insurance Companies a medicaid. Set of very complex issues that confront the telehealth providers and services throughout the country and a verys from state to state. What is permitted, what is not permitted, and what are the payment schedules. There is a lot to do. The federal government can do a big portion of it but the state is also important. There is an article that appeared in the Des Moines Register in my home state of iowa on april 13. It was entitled rapid rollout. TeleHealth Services in iowa were just going crazy with that one doctor says. It outlined many of the challenges confronting telehealth as well as how there has been an explosion of teleHealth Services in the state of iowa. And from that article, there out three things i pulled as lessons. The first is that the waivers we have relating to payments and the ability to deliver services, those things need to be made permanent and more regulatory requirement is needed to facilitate telehealth. Simplicity ineed our Health Care System generally. The federal programs and the state programs and all of the different requirements and hoops one has to jump through in order to qualify for this payment or that is so complex. Areas, and Rural Health Providers whether it is the doctor practicing alone or at the world health hospital, they do not have the staff to be able to manage all of these requirements. So, simplifying the requirements is so important for the smaller providers. And then third, we need investment in broadband as i alluded to earlier. One plate relating to that is many rural areas, a lot of them are served by the Rural Telephone companies or cable companies. Coops in many instances. There are thousands of small Telephone Companies across the country. They receive a lot of federal assistance through various means in order to provide service to their customers. And broadbent is quite good. The big problem is in rural areas served by the Large Companies in the country. Verizon, those companies. They do not receive that kind of reimbursement to serve rural areas and they do not have the incentive to make the investment as a results. Something needs to be done to address the Service Broadband service to rural areas served by the Large Companies where there is no federal subsidy or a assistance in order to encourage the delivery of the infrastructure that is necessary in those areas. So, i think if we look at those things, one, how to get investment in broadband, number two, how to simplify all of the requirements, and three, how to provide the regulatory relief i think some of these waivers becoming permanent and other regulatory structure changes will do a lot to help the rural areas. Would anyone else like to weigh in on that before we move on . Ok. Focusport recommendations heavily on stabilizing rural on a temporary basis to give them the opportunity to transform into other kinds of models that best meet the needs of the community. Why do we need to even think about these kinds of transformations . Do we currently have a mismatch between what some of these fullservice hospital and what the Community Needs . The answer is yes. About someing today of the responses that are already being proposed. I think we are going to see changes that have started as a id experience cov that will not go away. I dont and we are going to revert back to some of the restrictions because we have all been able to experience some of the benefits of allowing greater flexibility. For instance, we are speaking now from our various homes to share these views. Telehealth is going to change. It has been very important in some rural areas for years. It has improved significantly since i first observed it the in used in the early 1990s when i i would not want to have my body affected using some of the telehealth that was available then. Hastransmission capability improved significantly. The introduction of broadband in many areas, and we need to continue doing this. What we will have to do is sit back when we are out of the covid emergency and understand the benefits that we have experienced going through this adopt thosehoose to that have been very helpful. Toehealth i think is going fundamentally change how house care is delivered especially important for rural areas. Frankly, very important for cities where the distances may not be as great but the time it takes in order to get to Health Care Services can be significant. I think you will see many of the changes in medicare, in medicaid, and in commercial affairs being pressed to go forward even once we are outside of this emergency. , and all for the better. Anothercould just add issue and emphasize something tom said earlier. Telehealth is going to be critical and critical to telehealth is broadband. We have some real serious challenges in many parts of the world america especially in south dakota where many parts acquire evene to the necessary come a choir even the necessary, fundamental character of broadband to be able to access telehealth effectively. We are going to have to recognize that broadband issues are still unaddressed in many parts of Rural America and we have got to put more resources and far more priority on acquisition of good broadband if we are going to produce the kind of teleHealth Services that will be necessary Going Forward. This isnk if anything obviously going to accelerate these initiatives and most certainly should. Technology implementation basically has been fractured across this country and lagging in investment for decades. I spearheaded the , for example, when we were developing telecommunication laws. When you think about where we are today and where we should be. Some of the changes have been given a temporary designation in the emergency relief package should become permanent. We should begin the process now because we have to remedy the gaps that exist in our Health Care System and most deservedly and the health care communities. This will provide greater attention. We need to see the problem and the urgency that exists. And what we need to do as a country to provide a comprehensive examination of these issues and to address them in a concerted way. Let me get you to expand on that a bit. And i want to get back to the hospital transformation. We have proposals to allow one of the pathways, at least, for rural hospitals to transition and do something that would look more like a standalone Emergency Department plus some Outpatient Services plus maybe some observation beds and such. Course, the task force wrote these recommendations before we were intensely in the middle of and one of ourc questioners is asking is that could that potentially cause us to have a shortage of hospital beds especially like icu beds when they are potentially most needed . Aboutu talk a little bit why the task force decided to have some flexibility in these proposals . Course, weof heard from a wide range of stakeholders about the need for flexibility. To develop financially stable models. Over threeoccur years. Two years for the immediate Financial Relief that i cited earlier both regarding the sequestration cuts but also the additional assistance we recommend congress provides for reimbursements that we think is important. Are important. This would be a stabilizer and communities could then assess how they want to proceed particularly in the aftermath of the covid crisis and what impact will be on various communities and they can incorporate that. And the community that needs assessment. Placeld expect it to take in the next three years. 2023 for example. And incorporate these changes and then determine what essentially would be the forments for, example, the number of beds. I think the attributes of our recommendations give flexibility to the communities to determine what options or what model might work for them. They are not required to make those transformations. That is a choice and an option that would be available to communicate as they rethink about what their needs are for their particular community. That is why it is so important to do these state polls together. An arrangement between the health department, social service providers, minority populations, the tribal representatives. So we have a variety of stakeholders that have the ability to provide the kind of information that would be important to make a decision. What is also important is that this is not an immediate change. It would happen gradually over time and at any point at which the community and the hospitals decide they want to proceed down this transformational path. They could ultimately a adopt the transformation model and then decide that they want to revert back. For example, a critical access hospital. They could have it back pit t back and forth in the future when they determine what is warranted. Could you add a little bit to that . In addition to creating new transformation pathways, the task force also decided to provide various opportunities for how to pay hospitals. You spoke a little bit about this before. Why the need to provide some flexibility in this area and we arehere do you think headed or where we should be headed in terms of payment . How do you see us moving forward here . Flexibility oror the need for flexibility is that the rural areas in particular dont have many of the resources that the urban areas with their higher density have or can draw on. What we are talking about is, for example, the need for broadband is that an issue in most urban areas . We need to be smarter recognizing that we need to show some flexibility, greater flexibility then has been available in the past. Why i might comment on the results of being forced to be more flexible is a result of the covid19 experience is going to mean that Health Care Delivery, particularly the use of telehealth as a more normal way for clinicians and patients to interact come is going to change how health care is delivered Going Forward. It will be especially important in the rural areas because of the low density and high distances that are frequently required and because of the scarcity in some areas of certain types of specials. But it is going to change everywhere. I think the genie is out of the bottle now. People have realized how with thet it can be use of visual communication that ofpossible now as a result sites like zoom or other means to have telehealth, you can have many of the interactions between clinicians and patients without forcing them to actually be physically present. Not for everything, of course. But for a lot. , and as someone who is a former administrator, i understood the reason for some of the in flexibility is that governments are pressed to be fair in terms of how they treat differing areas. To always worry about fraud and abuse. And whether areas are taking advantage. But we have been forced to realize that rural areas simply need flexibility. That has not been available in the law and that if we want to allow people to remain in rural areas and want to enable them to receive the kind of health care that they need and deserve, we are going to have to be a little more flexible and find other ways to address any other kinds of concerns. As you know, one of the ideas we consistently heard from there arers is that other solutions if this does not work. That is the value of the approach we have taken in this report to get them options and then they can design it to their localits Health Care Delivery needs. As you alluded to earlier, when we were deliberating about the issues that are contained in this report, it was before covid19 hit and much of what we saw was that the Health Care Systems in the rural areas were structured for earlier years when there were more patience and longer hospital stays. Part of our deliberation was focused on how to make the system more efficient and sustainable. Casesould result in some and for example in fewer hospital beds in immunities. Now, with covid19 we have a different perspective than perhaps the one we had when we were deliberating about these issues. And that is that now, all of a sudden, there is a need for the ability to suddenly have an influx of patients and the capacity to meet this immediate, very substantial need. It is hard to do that in areas where you dont have the Financial Resources to sustain that kind of facility and every structure. I think we face a real dilemma in the country as a whole but particularly in rural areas about how much infrastructure the kind ofain for pandemic or emergency situation like we are facing now . For instance, what you consisting ongoing . That is a question of how much Government Resources would be more beds in rural areas then you need on an ongoing basis . I think the question that you asked is an interesting one and one that has arisen as a result of this experience of the last couple of months. Probably it was not given full consideration by us. One last point about this issue which will be response what is our Going Forward on capacity . That is going to have implications for rural and urban areas. Of how we canue better prevent the demand on capacity in the first place . And that really gets to more sentinel capabilities, more testing capabilities, infrastructure, more prevention. We are also seeing the whole host of social, societal problems right now that are being exposed in very meaningful ways. There is going to be a huge how orion about on what we have just gone through. Shouldreacted and what remain in place . It is exciting because in some ways, it might cause us to have a kick in the pants to address things that have gone unaddressed. I just wanted to elaborate on one point chris made and that is the importance of Public Health. Not only in rural areas but across the board. I wish i was shocked recently to jobs that we lost 50,000 in Public Health. Over 25 of the workforce in andic health between 2008 2017. We have seen a devastating attrition of Public Health officials at the local and state level. And it really accounts for a lot shouldproactive work we do to avoid these kinds of situations Going Forward. We have to recognize more of a need and a far greater investment in Public Health and we have in recent years. Let me just put in one question to my colleagues that has been troubling me. We are going to feel torn between being able to respond to the need for Surge Capacity but not wanting to have on an ongoing basis the volume of beds or icus or other Expensive Health care facilities that would be required during a pandemic or other emergency. So, thinking about how we can be smarter and how we accommodate the needs for Surge Capacity will again be one of the issues when we get through this Current Crisis that will require smart heads to think about. The use of the uss mercy and uss comfort and setting up a Field Hospital in the javits center. This will be useful to sit back afterward and income but upon all of us that care about this issue to think about how to be timer prepared the next Something Like this happens because as we all know, it will. We dont know when or what the cause will be but we can be quite confident it will happen again. Add to whattually gail is saying here. One of the proposals of the task toce, one of the pathways transformation involves global budgets. Would like to hear what you have to say and some of the others about how global budgets could potentially provide some flexibility to Health Care Systems and to states as a whole to pivot. Is atw that pennsylvania the beginning stages of testing a Global Payments model. And the recommendation of our the force has been to ask center for medicaid and medicare toovation to look at how expand on that model so that it could be workable for other states. We know that the pennsylvania model was geared specifically for pennsylvania. With the idea of Global Payments, it is to get government to step back and not put constraints on the various elements in spending that a state or a hospital or a physician might have to be accounted for. We have been moving in the direction of more and more Global Payments since the 1980s payment wastive adopted as a model to reimburse whereals under medicare the payment was based on the diagnostic at discharge. And how precisely the payment was used was left more up to the hospital. There are various issues that have arisen about whether or how to account for quality when you get Global Payments and whether or not to put some kind of reporting requirements or quality requirements in but the basic idea is to give the state or the hospital a governmental governmental unit in how that funding is spent. Either asuid pro quo government or as us, the potential using public, will be what do we want to know in giving greater flexibility to a state or to an institution . What kind of reporting what make us feel assured in the areas that matter . Is having provisions that certain atrisk populations are being properly cared for . That would be worth our time. In the way we take the positions under medicare, we move from a micro level with a relative value scale where you have physicians being paid on the basis of 10,000 units to various attempts to try to get more valuebased payment. We are still struggling in that are andarding where we at that point, where we need to be . E. These are not easy issues. Getting to broader payments allowing more flexibility and deciding what information and assurances need to be provided is a far better position we find ourselves in. Great. We have been talking really about the hospitals in rural areas up to this point. I wanted to ask you all about the needs, really, of clinics. We have rural Health Clinics oftentimes attached to hospitals and we have qualified Health Centers as well. Ae of our models would allow clinic or a federally qualified Health Center to expand services when the area has lost Hospital Services or lost the hospital altogether. Addllow them to expand, to say Emergency Services and get paid properly to add that. What is the issue we are facing here with the clinics . And when we are seeing hospitals disappear, are we seeing the clinicians or the clinics disappear as well . What is the need here and why was this response chosen . A real shout give out to the community Health Centers which have done a phenomenal job. They are overwhelmed right now because in many cases, people have lost their Health Insurance as a result of the dramatic increase in unemployment. Americans have filed for unemployment insurance. Unemployment claims. And as unemployment continues to become more severe, the clinics around the country and especially in Rural America come are feeling the full impact of the initial demand. Resources are going to be critical. Some degree of recognition of many of the things we have already talked about providing them with greater flexibility, maximizing scope of practice doing all we can to ensure the clinical infrastructure has the resources and the ability to meet the demand. That is critical and im not sure that we fully appreciated that to date. I think there will be more even inn placed on that a 3. 5 as chris noted. Looking at the fourth phase, those resources will be essential and we have to make sure they are given the priority they deserve. I totally concur it is clear that rural Health Clinics play a pivotal role in Rural Communities. As medicalibly serve communities in certain areas. Of providersumber that might not otherwise be a available in a rural area and are ready for hundred Health Care Clinics have been created since 2012. Federally qualified Health Centers. Residents are served and there is an impact of 3600 jobs. Clearly, that is devastating and we really do have to recognize and provide resources and to elevate the reimbursement as well for rural Health Clinics. It is one of our proposals for independent physician owned that receive a lesser reimbursement than the hospital providing 115nd the visit and an increase in Nurse Practitioners and physicians assistants so they can expand the offerings. These are the types of approaches and issues that congress should be evaluating as well. Ok, ob services. We know that hospitals having closing. When they are not closing or before they close, a lot of these hospitals are cutting their ob services. This is a very expensive unit for a hospital. We know that. Not just in rural areas. And it is generally a money loser for hospitals. Why did the Task Force Recommends increasing payment rates for ob services . The task force also recommended careings for primary clinicians and other clinicians to allow them to better be able to handle prenatal care and also frankly, deliveries. Fromg our visits, we heard one Hospital Executive that they had stop and drops. We asked what a stop and drop , well and the guy told us come a dont have ob services yet we are having a lot of pregnant women coming in. They are in labor and ready to deliver the baby but they have not had a day of prenatal care at all and we do not have ob services. The problems with the lack of ob services are affecting outcomes, frankly. Why is this so important . How big is the problem . Why are we recommending increased payments and training . I just answered all that. I dont know. I was going to say, i think you really did. [indiscernible] the question for us. Going to welcome and encourage a young family to stay in rural areas, you need to make it easy for young families to expand and that means having of star trek Services Available. To make itant impossible for families to be areas oreliver in the to have to go elsewhere. If you are serious about wanting to have rural areas be able to support young families, you need that of star trek all services are there and you need to make sure that pediatric care is available. These are the Main Services that young families need and without them, you will be fighting a losing battle. Ournd how big a problem payment rates for ob services whether rural or not rural . This has been a struggle because of the nature of the payment tends to be a single payment made for obstetrical services. If you do not have a large cases,of obstetrical those kinds of averages can cause a real problem. And it is why several of us in our discussions have particularly pointed out the need to have obstetrical payments which reflect the lower use but very critical nature meansaving ob services and that was why the recommendation for having National Averages rather than having it just for the local area that might be involved. It is really recognizing that if youre going to track and be able to maintain young families in rural areas, you have to provide the services that are most important to them. Ok. Let us move on we have not talked a lot about the workforce challenges. We certainly have a lot of workforce challenges right now with covid19. But beyond covid19 in rural areas, we do have an extensive problem with workforce. In rural areas, what makes it hard for clinics and hospitals to get people to the rural areas . What are the challenges in getting them to stay there . Why is this such a big problem . From thespeak experience i had over the years representing south dakota. Communitiesler struggle these days because they are older. They are sicker. They have greater demands. A physician or Nurse Practitioner in a small, rural setting is onthejob 20 for seven which is exhausting. 24 7 which is exhausting. For arvices are looking more balanced life and they know that if they moved to a Rural Community, a norm demands will be enormous demands will be put upon them. Part of the challenge is the existence of such limited access to providers in these rural settings. I think that is part of it. Oftentimes, as a physician or nurse come youre looking for places to raise children and limited access to other social services, community services, and the kinds of things you expect in normal and urban settings do not exist in Rural America. It is hard to recruit for that reason and that is where think we have to create a robust Incentive Program whether it is tax relief, finding ways to ensure that these physicians and providers can be compensated more robustly. Given what we know now, it is just an anonymous demand personally on them and on their families. Go ahead, congressman. Go ahead, chris. I was just going to say wein, this is not new but have seen these challenges thater and gail mentioned mentioned the difficulty of attracting spouses as well. You cannot just think about the and their financial incentive. You have to think about the attractiveness to the family. That becomes harder and harder when you think of these things. I do believe that this task force expressed frustration about just doing the same old same old which is why one of our proposals really is to be aggressive on the whole workforce issue and put new ideas on the table. Iat i outlined previously so wont go through them again. And i do believe that the telemedicine capabilities, if we can really address the broadband on thishich everyone zoom meeting pulled our hair out on this issue. At all three of these senators that have been raising this issue and i cannot look at them without thinking about that. I do believe the infusion of dollars the first place wasress went for covid19 putting substantial dollars into telemedicine. Gales point, when people see that and see its potential capabilities in well served macys that as something we can build on and justify some significant investment in the broadband area. But come i will turn it back over to the congressman. I was simply going to say that what tom daschle said was accurate in terms of the questions related to lifestyle and availability of good schools and all of the other potential issues one has in rural areas. Another big factor is this whether rural or urban areas, physicians very few physicians practice alone. An urban area that the single practitioner has gone away . Paperwork andthe the regulatory challenges. I alluded to this earlier. Our system is so complex, we cannot understand our own insurance, most of us or why it something gets reimbursed or doesnt or the amount that gets reimbursed. If you are a single practitioner in the rural area and you have to try to work through all of , thefor medicare, medicaid areas insurance programs. The paperwork and the bureaucracy you are dealing with is overwhelming. Most physicians do not have to deal with that because they have back office staff that takes care of those things. I think one of the challenges come in addition to the lifestyle issues and people make different choices about that, one of the challenges is how do you get people who are practicing metal medicine in rural areas, how do you make it possible for them to spend their time engaged in working with patients rather than having to deal with although the paperwork we have had some questions about why we dont focus enough on frontier communities. This is building on what we did in our earlier report a couple of years ago. It is a combination of these two reports together that give us a comprehensive view of our concern for rural health. This is something we need to look at. I am glad you raised that. I want to make sure people realize this is built upon a Previous Report that we put together. Staff visits in the. Akotas Frontier Health was a particular issue. Thank you for raising that. We should post that. Lets go ahead and do that. Of the reasons why the task force decided to offer as many different pathways and Payment Options as possible. So states can be flexible. The one thing we heard over and over again as we visited rural areas is if we have seen one rural area, we have seen one rural area. Every area we visited was very different. Different needs, different infrastructure, different workforce challenges. We feel like we have a lot more work to do. This is the chance to offer many options. They are not getting the same amount of attention as hospitals are. When people talk about hospital relief. It also involves significant dollars for primary care physicians. Is a moment in time when people are not going to their physicians. If you are one of those who , iught about retiring early am really afraid. We could see these offices closing at a time we really need them. As much as we talk about hospitals, we need to talk about physicians offices. Giving them stopgap protections. One of the questioners asked nurses,e role of primary care physicians, teleHealth Workers. Should we be paying education expenses for people who enter the shortage areas . I am a big supporter of using loan forgiveness. Attracting people who you need and are not able to attract. Is increasingly effective. This is something we could make more extensive use of. Even for physicians. We can do that. Historically, this is not worked as well. I would agree. I think there is a critical consensus but we have to continue to explore other venues. We can workake sure on these kinds of initiatives. One of the areas one day comes to workforce is access to mental Health Services. What people in rural areas told us was very high on their list of concerns about access. Why is it a bigger challenge in services . S to get the is it possible that this new telehealth ability is going to help in this area, even beyond covid19 . This is an area that the military has actively used. This may be something that is not obvious. The military has reported Successful Use of this. There is a shortage in terms of mental Health Services. Rural areas are competing with urban areas. This is a place where one of the challenges has been given the amount of time. It may well be an area where there are support and Health Workers who are not being used as imaginatively as they could. The militaryhing may have some resources to share that would be useful in providing health care. It is fair to say that there are very few mental Health Professionals in most rural areas. There is a bigger shortage in the Mental Health areas. There was Significant Growth in mental Health Services via broadband tech. Not just mental Health Services as we think of them but also things like family counseling. We are sheltering in place now. Of the stresses and strains of family life can be exacerbated during this time. Having access to Counseling Services via telehealth makes a lot of sense. It is also a real help to a lot of people. One of the things this tells us servicesmmunication that can be available in rural areas. I think we are getting down to the last five minutes. We are just about out of time. We would love to have your final comments. What is most important to you . I want to thank the entire staff and our sponsors once again. This has been an important project. I could not think of a more timely effort than what we have now witnessed. I appreciate all of the work that has gone into this. The commitment in time and effort. Thank you to each of you and to our great staff. Thank you all very much. My continued gratitude to all of you and everyone involved in this process. And to our viewers. We want you to provide feedback. I hope this will draw attention and consideration in congress. As they move forward on some of these issues. We look to the report from senator grassley and the finance committee. We will use this as a catalyst. A significant change is warranted at this time. I serve on the board of the bipartisan action center. The Action Network needs to get to work. They need our suggestions. It is tough. It is a tough time to push these things. On the other hand, with crisis comes opportunity. This crisis has shown the need for and benefits of telehealth and other things that improve the services of Rural America. We need to find a way to make sure that the flexibility and use of telehealth is continued ande reimbursed by medicare especially by the private payers. Medicare and medicaid have enough pressures that they may be more amenable. I will conclude by saying it really has been a great privilege to work with my Task Force Members and the staff to produce this report. This moment is a thertunity to build on focused attention that we are seeing on the limitations of our Health Care Systems and the opportunity to overcome barriers to access. In a much more efficient and effective way. There is a big appetite both now and into the future. You can feel it. People all around washington are focused on, how do we use experience tohis improve our Health Care Delivery system . I know the Bipartisan Policy Center will be involved in that process. I am very excited that this group on this screen will be a big part of that. I should take that opportunity to let folks know that we are launching a Behavioral HealthIntegration Task force where the group will be working to gather to break down barriers to integrating Mental Health and behavioral Health Services with primary care and physical Health Services. Thank you. It is not just in washington. Who areso in the states looking at how this can better improve. I think this is a federalstate relationship we will have to work with. I want to thank you all for joining. A number of people have remained on the whole two hours of this. That is really great. I want to apologize. This is a new experience for us dealing with this new kind of technology. I want to apologize to congressman small for the glitch we had with her video. We went to give a shout out to the staff. All the work the staff has put into this. We all hope that we will take work andur advocacy continued to advocate on a number of these recommendations we put forward. We hope they consider it in the current package or there will be more packages as we go forward for the rest of this year. We have another video webinar tomorrow. You can go to the website and get a link. Theill be talking about interaction between Artificial Intelligence and how it can be used in the current pandemic. Thank you all for staying in. Stay in touch and stay safe. [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. Visit ncicap. Org] [captions Copyright National cable satellite corp. 2019] members of congress are working from their home districts. 30 are in the automotive industry. The other majority are frontline workers. Now they are considered essential workers. These are the people who helped put groceries on the table. They have been demanding minimum wage. It is important to highlight that they are keeping us afloat. This is a very serious issue. To the federal authorities, state authorities, local authorities, Health Experts. Stay away from people. This is a war. The u. S. Is at war with this virus. Thetay in touch using cspan congressional directory. That is all the information you will need to connect with your senator or representative. Order your copy online. Dinner in 1988. [applause] you. Pres. Reagan thank thank you. [applause] fmr. Pres. Reagan thank you. Thank you very much. Please. Thank you all. I am delighted to be here. My, what a crowd. It looks like the index of larrys book. [laughter] [applause]