Transcripts For CSPAN2 Capital News Today 20130727

Employers can do. Its critical whatever ideas come out need to be extremely appropriate for Small Businesses. Because for hispanics, were we are more likely to work for smawses Small Businesses that have less than 100 employees. They are less likely to offer a retirement plan. Thats because the industry has not offered products that are relevant to small employers who have lowincome workers. So we need new why why the ideas. Its important make sure that businesses not be burdened financially or with liabilities and so on and so forth. They will do this. But, i mean, i think people have a moral responsibility to try to help improve the Retirement Security situation of all workers in the country. I want to point out the automatic ira also does not employers cannot provide a match. And there is a i know certainly in the president s proposal and others theres an enhanced employer startup tax credit. I think were out of time. So thank you. Thank you very much. Im going call david. You can clap. [laughter] [applause] in pho few moments on a discussion on Rural Communities face if accessing health care coverage. After that another chance to see the u. S. Chamber of commerce and aarp event on retirement planning. . Rncht on this weekends news maker ron widen wyden of oregon. He talk about the nsa Data Collection program and the view on the federal governments patriot act. Heres a preview what senator wyden had to say. All of the bipartisan votes support for an amendment in the house this week is part of the defense appropriations bill. Are you working on a similar proposal with democrats and republicans in the senate . Im definitely working with democrats and republicans to overall this program dramatically. Theres a number of discussions already. Senators on both sides of the aisle and the discussions certainly have accelerated since that extraordinary house vote. We have already a quarter of the United States senator on record saying they are interested in pursuing, certainly, the issue that are central to the debate. Thats the reason we insisted on finally getting answers. The answer to your question is yes, youll see a strong and bipartisan effort in the senate to pick up on the work of the house and to fix a problem that i think intrude on the privacy and liberty of millions of lawabiding americans. You watch all of of senator wydens remarks. The first lady reflect the United States about what women are supposed to be today. Are we suppose to be mom supposed to be first meat . To navigate that if the president is supposed to be head of state, and head of government, is the first lady supposed to be, you know, the ideal fashionist that . Is she supposed to be mom and chief . Is she supposed to be first mate . But at the same time if shes going to be first mate that means shes got understand what is going on in the administration, shes got understand what is going on in the country. And shes got to understand her husbands political agenda. You cant really separate, i think, how the first lady presents herself, and the conflicting expectations that the country still has for working wives and working mothers. As we continue or conversation on first ladies. Historians talk about the role of the first lady and the move from Traditional Home and family to activism on behalf of important issues. And the transitioning from public back to private life. Monday night at 9 00 eastern on cspan. A discussion on the challenges Rural Communities face in accessing health care coverage. Panelists highlight certain initiatives as well as medicates role for the issue. Its an hour and 45 minutes. Why dont we get started . My name is ed. I want to thank you for coming. I want to welcome you on senator and the board of directors to the program to look at health and health care and Health Insurance in Rural America. We know more likely to be uninsured less likely to have employer sponsored coverage. Which, of course is the most prevalent way of getting coverage in this country. We know that geography poses a particular problem to gaining access to needed care in some rural area. We know that just in the case of urban areas that the Affordable Care act is going to have a major effect on Health Care Access and coverage in rural areas. So today were going take a look at the issue as well as potential policy changes that might address some of the challenges that your going to be hearing about. Were pleased to have as our cosponsor the corporation which contracts to provide medicaid coverage in what almost twenty states. And operates a number of Services Like call center and Behavioral Health. Comoderating the discuss today we have the state, the Health Care Industry and others responding to these challenges. The briefings also provide opportunity to learn about innovative initiatives that help improve the access to delivery and quality of care. And weve focused on coordinating Health Services recipient of medicaid, medicare, and our program to help the uninsured. We are pleased its an area of great interest to the hill staff as well as the policy advocacy and research communities. Im looking forward to todays discussions in this briefing and the opportunity to exchange views and discuss best practices and rural health. Thank you. Thank you. A couple of housekeeping item. There are material in the packet including Powerpoint Presentation of the speakers. Theres also a onepage sheet of materials that lists all of the written stuff that is in your packet, and a bunch of other things all available online. Excuse me, online at the Alliance Website which is allhealth. Org. If you watching on cspan and have access to computer or other internet device, you can get the same material at allhelp. Org. There is a web cast and pod cast available next week on our website. A few days after that a transcript of the briefing in case you want to relive the exciting words you are about to hear. [laughter] we would like, at the appropriate time, if you would fill out the blue evaluation form in your packet so we can improve the program with you as we go along. Theres also a green question card once we get to the q a. There are microphones you use you can fill out the green card and write a question. Well try to address it up here. About that evaluation, by the way, normally about a fourth of you take the trouble fill it out were grateful and hate the other three threefourths. [laughter] we have a prize that we commonly do our colleagues. If that number rises to 35 , the alliance will donate 50 to support the healthy corners project of the dc central kitchen. That. Project, which i learned about, promises im sorry promotes Community Health by promoting the availability of fresh fruits and vegetables in d. C. Specifically in the citys so called food desert. So 50 of you complete the evaluation, well go to 100. How is that . So do we have yes, there is a url at the bottom of the slide. In case you want to add your own donation to the one the alliance will be making. So that is the end of the commercials. We have a great panel for you. Were going do ask them to give relatively brief presentation and open it up for discussion among the panelist and your questions. Were going to start with keith mueller. Keith, who is both the directer of university of Iowa Department of Health Management and policy, and head of the senator for Rural Health Policy analysis at the Rural Policy Research institute. Were pleased to welcome keith back. Hes mr. Rural health. Thank you very much for being with us. Thank you, its a pleasure to be here. Thank you it to the alliance for sponsoring this and all of you for being here. My past in the opening presentation is provide overview backdrop to what the current state of affairs is in rural health in america and some of the efforts underway to improve that. The Current Situation as the slide said circa 2010 thats the date of the data that is important within the particular side. As ed was saying with the employmentbased insurance situation in Rural America is lower than it is in urban america when we look at characteristics of the uninsured. There have been recent increases in coverage in Rural America primarily through Public Program and in particular through the Medicaid Program that really is a function of as a proportion when you look at residents below poverty. The income below poverty is lower in rural than urban and higher eligibility for even the current Medicaid Program before any expansion. And difficulties that Rural Americans have in finding broad and affordable coverage in their individual and Small Group Markets. In availability of services in Rural America, most of the shortage areas in the country, whichever profession you pick, primary care, Mental Health, dental health, those shortages are disproportion theirly rural. Providers who are are our bedrock for acute care, Mental Health, oral health, and Rural America operate on much tighter margins and most counter part in urban america. We are in a situation though in the in which there is more stability in the rural provider arena in Rural America today than there was when i started in this field a few decades back. Because of a lot of policy interventions that have been tested, tried, and implemented during those years. So one of the thing we talk about a lot when we talk about Rural America and the provider communities is maintaining the Success Stories that weve had through changes in payment policy changes and how we recruit and retain professionals. Next im going to intersect that with some of the provisions that are in the Patient Protection and Affordable Care act otherwise aca. Object insurance side, insurance reform that have already been implemented during the first couple of years of the aca have had an impact such as coverage for children up to the age of 26, creation of an essential benefit package that becomes the baseline, which is an improvement over much of what has been available in the individual and Small Group Market in Rural America. The elimination of lifetime limits on benefits financially for house hold. And the removal of preexisting conditions as a reason either to deny totally access to coverage or to say you can have coverage except for the condition that is a preexisting condition. Sometimes theres a writer on insurance policies. Thats one aspect of the aca. Another is the new marketplace that are developing now in the individual and small employer. More rapidly on the individual side as you have been reading then on the small employer side. But developing in both. It would be beginning to see some of the results of that in term of what the premiums are that the health plans said they will be charge in these new marketplaces around the country. Finally, the intersection on the insurance side with expansion of the Medicaid Program to the 138 percent of the federal poverty level. Other intersection in what i was talking about in services in Rural America. Its effecting the ability of safety net. Work force expansion that was entitled v of the aca that doesnt gate lot of play has been very important to Rural America. Meeting some of the work force through casual Health Service corp. , new Nursing Training program ands other. And availability of service that were seeing through changes in the Delivery System. There are questions we need to be asking as to market place developing rural places or in states. Whey that need to gain access instead of dollar and cent. They need help in affordability of coverage and deciding how to take advantage of new provisions related to affordability of coverage. What might be differing about the changes in rural as compared to urban marketplaces are certainly difficult and how do policy choices effect what is available to rural residents. From some of the research, these are in the document you have that we are doing as well as others much in is what it looks like in the exchanges. There are state based exchanges slides of 17 states. Its 16 state in the district of columbia. Partnership between federal facilitated in states and seven and 27 that are using the federally facilitated exchanges. For Rural America were looking at characteristic how the market function in the new model. The govern then of those exchanges, support for enrollment activity. How it tran pyres in rural places. Access to services and how we certify the qualified plan. Shifting to the characteristic of the uninsured and another document in the packet that we released earlier this week. A larger portion of the rural population escaped specially the uninsured would be eligible for some of the expansions whether its Medicaid Expansion, or the new subsidizes than in urban county. Thats the general conclusion of both bullet. A larger portion of the rural uninsured are inhouse holds that will become eligible for either the subsidizes or Medicaid Expansion. Assuming for the moment over the next period of time medication expansion becomes striebl all of them. What were doing to invest in rural Health Service on the availability side, the Community Health center fund that was created in the aca have effected access to care in rural places through the Grant Program and the 229 million of new expansion money in the national Health Service corp. In system change in rural places, ill focus on the key example, which is a Accountable Care organization. These are new organizations set up by the aca in the Medicare Program whose intention is to over a threeyear period generate cost savings while maintaining a standard of quality that set fairly high and the cost savings are shared between the Medicare Program and the providers. We didnt know how rapidly it might catch on. The numberses are higher, i think, than any of us expected coming in. As of a few weeks ago, there were 32 what are called pioneer. These are more mature organizations that bear risk across different payer types. They are now at 23 within the last month. Nine decided they needed to pull out of the program. There are 23 now pioneer acos. 220 Medicare Shared Savings Program aco, 32 of which are called advanced payment. They are getting special pavements payment ahefime that get repaid out of savings so they can invest in setting up the aco. There are more than 400aco total public and private. They are in rural places and every region of the country. There are 79 in both metro poll they operate in over 17 of counties. There are nine that are exclusively in rural places. Very quickly its the color version of the map that is also in your packet that shows the distribution across the country. Ill close on a little bit of microcause m of what is happening to my own state in iowa as an example of the activity both marketbased and aca based. Iowa is one of the states that is a federally facilitated exchange, but a state Partnership Model for that exchange. Were proceeding in our state with the developing at love material for consumers, a Public Policy institute at my university is participated by generating survey data to see what Consumers Want to know about, how would they like the message delivered, what are some of the key words and phrases that resonate with consumers. Theres a lot of progress being made on how to reach out especially as we get close to october 1 in enrollment time. There are two staidwide carers in iowa that will offer plan in the new exchange. One of the carriers is actually one of the handful of state coop around the country. Our approach to expansion is expands the medicaid el diswroibility 100 and use medicaid dollars to help purchase plans through exchanges between 100 and 137 of the federal poverty level. We have a priority for Work Force Development and dispurrings across the state. New state spending in that regard else new universitybased program. We are moving forward we grated system including Accountable Care organization as the meth dolls being used in the expansion of the Medicaid Program. Thank you for your attention. Ill shift it over. Can i ask before we turn to tom. You talked about sort of expansion with medicaid under 100 and private insurance over that 137. That that been approved by hhs . No. I think the application is just about ready to go in. To clarify a little bit as a 100 to 138 still considered to be part of the Medicaid Program. What theyre doing instead of having those individuals and house hold get share benefit directly from medicaid. They are using medicaid dollars in federal to help them purchase plans at no cost to them to buy one of the plan out marketplace. Very good. Thank you. As keith said. We turn next to tom. Hes the head of the office of Rural Health Policy within hhss Health Resources and services administration. He served as the associate administrator for Health Policy for the last five years. Tom, i didnt gate chance to say hello before the program began. Hello. [laughter] thank you very much for being with us. Thank you so much for the opportunity to be here. A little bit about our office. Were located in the hhs hhs administration. Our Office Actually has a Department Wide charge to coordinate rural activity within hhs. And as part of that, a big part what we do is keep our eye on the policies and their impact on Rural Communitieses. We do that through analysis but also working with a series of Research Center including keith at university of iowa. We have a number of Grant Programs, i think, that focus heavily on Capacity Building both at the state level and at the community level. Then we are very, very much focused on Technical Service to Rural Community to help them sort of navigate what is becoming an increase belie complex health care environment. A little bit about our policy at work. We basically review all the medicare and medicaid aca regulations that come through the department each year. Thats hundreds and hundreds of pages of regulations. How does it effect access in Rural Communities . Thats sort of how we take the charge. We raise the issue that could be a concern. We make sure theres a level playing field. In other words policy should be preed candidated on that which effects everybody equally. Not focus solely on the largest area of our country. Something that takes in to account the unique circumstance that every community faces. Obviously we also focus on other regulations coming through. We had a looking at the meaningful use regulation around Electronic Health records and quality has been an increasing area of focus. We want to make sure we are measuring things relevant in a rural care setting as they would be say here in washington, d. C. We could not do this without the support of our Research Center who provide a lot of analysis and data that helps support the point. We also work for the group out of oklahoma, Oklahoma State university, the intersection of health care and Economic Development in Rural Community. Typically in a rural area. The hospital would be a number two or three employer. It take on bigger impact as a result of that if a hospital closes or if expands the services. Automatic of those things have bigger implication in Rural Community than a suburban area. In term of our policy. We are staffing secretary nationalled a provide i are committee. As my office has to charge to advise hhs internally. The committee which is chairmaned by former mississippi governor and includes health care and Human Services expert arnt the conned. For the last few years they have been focused heavily on the bank account of the aca on Rural Community. They produce a series of briefs that look at different provisions within the aca. All with an notion of perhaps on the Front End Department on things they ought to take before they begin rural making. And one of the brief i would draw your attention to. All of which on the web is one they did last year. Some of the deficit reduction proposal being proposed by the congress or administration looked at changes to rural hospitals designation and specifically critical access. I think the committee did a nice job of looking at the impact what the policy changes might mean for after the community they served. I think any time you talk about Rural Community ed alluded in the introduction you have to start of realize that rural is not a smaller version of urban. Or smaller version of suburban as you anemic characteristic. Some of which ed cited nicely. If i could add a little bit to that. In addition to the fact folks are older and sicker. Theres a higher mortality rate in Rural Community. You have a different provider and service mix. You are focused on primary care and chronic disease management. You may not have access to the Specialty Care as urban area. Access to the full range of services may not be the same in Rural Community as in suburban or Rural Community. They are more dependent on public payers. We have hospitals where the payer mix when you look at medicare and medicate make up 70 to 80 percent of the total pay. What that means is any sort of change we make in policy, during the medicaid or medicate level tends so have disproportionate impact because the decency. I race raise this to make the point when you think about policy solution as health care changing raptly you have to do so thinking about the diversity of the infrastructure and the Delivery System out there. In other words just because we worked in urban urban area. I know, that to co of this is on access and work force. There are a number of things that were doing around access i think keith data point out the opportunity that Rural Communities have under Affordable Care act and the data he cited its similar to the data we have in the department. That looks at the fact that on per person basis, we have a potential for more rural folks than for throughout the expansion than the urban counter part. But the other thing, i guess, i would say is that the next couple of months are critical in term of getting the word out. We are putting a push on the department making sure people are aware of it. Were driving them toward health care. Gov the newly revamped website and putting information throughout and also funding to help the navigators to work enroll people in the insurance option come october 1. We put pounding funding tout help them with the enrollment. There will be a sixmonth Enrollment Period where people are able to sign up for the plans. Reaching tout Rural Community may take a different effort than reaching suburban or urban area. I think thats why one of the approaches we are taking as a department you can can submit a application by paper. Not every rural activity has the kind of Internet Access. Once you have insurance you need the providers to do it. And keith mentioned Community Health center and the Important Role we play. There are 8,000 Community Health Service Center around the country. 40 of are located in or serve Rural Community. Rural health clinic. Theres 4,000 around the country. They also play an important safety net roll in key access point for primary care. Through a Grant Program in our office the Rural Health Outreach program. We test new idea and Pilot Program to improve access to or coordination of care in Rural Community hoping question replicate them other areas. We also do a lot of work with rural hospital through the Rural Hospital Flexibility Program and small hospital improvement program. All with an eye of improving financial so they can continue to thrive and be access point in the Rural Community. And in the final area would be the we put grant out to help support test beds for finding out how question use the technology to increase access to care for say a specialist in urban area be able to treat a patient in a rural area. In term of work force, we have a number of tools that work one of the things we focus on of late is trying to do more training and Community Based and rural settings. About baste example of that is the rural training tract. We found that 23 now in place about 70 of the graduate of the resident sincerity programs stay in rural area. We are trying to expand a number of those. I have five new prament programs that come on this year. We hope to get the same number next year. Our Teaching Center program is another example of trying to get some of the physician training out of the academic Health Center and Community Based settings through a pair of people for the reality what theyre seeing in practice. The National Service mentioned 50 of the placement in the national Health Service corp. Go to Rural Community. There are other programs such as state conrad 30 allowing positions to stay in rural area they agree to practice for three years. All the programs are part of the safety net to give workers out in to Rural Communities. The other thing that is as really a wonderful opportunity over the last couple of years has been the creation of the white house counsel. It was created by an executive order by the president in 2011. And the charge was fairly straightforward. How to better coordinate all the federal agencies that serve Rural Communities. And so we have been front and center in at love activities, and we have focused a lot on jobs and Economic Development. As i mentioned health care is a major employer in rural area. Health care has been front and center. What we coin the regard. We have expanded it to critical axe excess hospital. We look at trying to train more workers and Health Information technology. Thats a growth field nationally but particularly in Rural Communities. And we think that rural serving Community Colleges can play a key role. We looked at way with he make it easier for the providers to practices for the full scope of training. And so the past year we introduced a Regulatory Burden that looked at way nurse pray ticksers could do nor the settings they are in and have a lighter Regulatory Burden as a result of that. I think all of the is done within an eye toward either the period were facing now which is health cares changing that draymatically. We are seeing a lot of consolidation going on in the industry. We see an increase focus appropriately on quality and also seeing an increased to cannous on trying to manage cost better. One of the challenge is what does it mean for rural providers . We think about the grant work, our Technical Assistance work, or how review our policy regulations what can we do to make sure we help rural providers survive the transition and not only survive it but thrive in an environment in which more focused on value and less focused on volume. And so this is an illustration of that. It will be part of what were doing over the next couple of years. Thank you so much for the opportunity to be here, ed. Great. Thank you so much, tom. Okay. At the other end. Were going turn next to dr. Art cofman. The choice chancellor for community of health at university of new Mexico Health science measure. Hes an internallist and family dock and the list of Innovative Program he put together at the university is as long as lebron james arms, i think. One of those innovative projects is the development of Health Extension rural office. We asked them to tell us a little bit of the office today among other things. Thank you for joining glops thank you, ed. I want to talk to you about two programs you probably dont know much about. But we think are very important. Both of them are in the Affordable Care act buried in there section 5450. But actually we have brought these up and have had a powerful impact on our state. We think it has in play indication for rural Health Across the country as well as urban area. We think that the our addressing big challenges we have especially in academic Health Centers. And those challenges are that almost all the training and role modeling are at big center and big cities. And when you look at the health team its far narrow to the kinds of problems faced in Rural America. Then l we are missing the boat. All the money we spend in the United States it has a little impact commence rate or not commence rate with the amount were spending. So we decided to have a radically different vision for Health Science stoarnt address the rural and urban Health Crisis we face in our state. And we came up with this challenging and as you see competitive vision. And its with our academic Health Center and Community Partner to make it health and equity than any other state by 2020. The challenges is out there. Our chancellor is terrified. We have seven more years. Are we making progress . You can imagine. I have to answer this every day. And what is most interesting the operative word, health. Its not just Health Services. Its all of those things that underlie health. And some of the biggest things that underlie health are not really the lack of doctors or nurses or the presence of them or pharmacists or ot or pt. Its the social determinacy. Adequate housing, access food talking about food deserts. Stress, exclusion social exclusion. Educational attainment. Transportation. All of those things have a huge impact on health. Im going give you an example in new mexico if you look at dpret dynes in our state, the native American Population has the best screening treatment for diabetes of all the ethnic population in our state. And yet they have the worst health outcome. The highest death rate from the disease. Why . Its not because the screening and treatment is bad. Its because that comes too late. It came make up for the fact decades of poor nutrition, high stress, very low educational attainment, poverty. All of those social determinacies. Sop if were going it make an impact on the state. Its true of every state how is all the money poured to the Health System going to be chaired with those who actually impact social determinacy . So we looked around and found one of the best model is an Agricultural Extension service. Now its a different sector. We are talking about agricultural. We are in health. When we look at agricultural the cooperative Extension Agent they deal with Economic Development. They make sure farmers have greater crop yeegdz. They help their youth graduate from school. Do better through the 4h club. They help proper canning for safety. They help improve nutrition through lots of nutrition classes. So we decided were going to copy them. Steal their name, and run off and have Health Extension coordinators. We have them all over the state their primary role is link the communitys Health Priority with a Health Science center for resources. Move the control out of the Health Science control toward the community. Its been successful. They not only help make the programs respond communities priority. Nay monitor what is happening. And now we have these different part of the state and theyll do all kinds of things. For example, they help with reducing open yoid treatment. They find that one of the biggest problem in rural new mexico besides primary care are dental problems, and especially Behavioral Health problems. If you youre in a small town and have Behavioral Health problem. Are you going to the local Behavioral Health provider with a sign and everybody dries by and said whose car is that . The problem of access are huge. They are been training all over the state lot of First Responders people in Mental Health first aid. Its another response they set up to have a pharmacy to keep pharmacies going. They do a lot of work in trying to get kids to stay in school. Graduate and go to health careers. If you look at the number one employer in some of our Rural Community. Its the Health System. And dallas county. 65 of the new jobs were in health. If you can get a doc to go a rural town. They hire 18 people. They generate a Million Dollars in business. Its a huge economic driver. A big social determinant. Just like educational attainment. The success of this is lead us to develop health hubs academic extension hubs. Where its not just the provider. Its linking with Community Colleges, federally qualified Health Center, local hospital, specific organization. Where now we have memo of agreement going out where those. When you have a hub like that. Its attractive to Health Professional to be recruited and stay. Because they have professional and social bonds reducing isolation. So that success has been enormous. Then to track what is the outcome. We often spend a lot of time training. When people finish the training in pharmacy and medicine goodbye, have a great life. Its not good enough. We want to know where theyre going and whether they are meeting state needs. We track in every single county for a population oflet say 56,000. How many docs, nurses, pharmacists should there be compared to what they have . For that gap, are we responding . Are we connecting with all of the other Training Programs in the state . So we are beginning to develop that response. Thats been powerful. Then we want to know how do we actually measure ourselves against other states . This is just an example. You can look at Something Like primary care providers for 100,000 population. In new mexico back in 2010, where we were like 113. 6. If we want to jump three states worth, we have to hire, we have to train and deploy 50 other primary care docs. Its quantitative. High School Graduation rate. We are one of the poorest in the country. We would 1,500. Graduate 1,500 more kids from high school to jump three states worth. We are making it quantitative so everyone can see on a temperature chart whether we are getting closer and closer. Now the one newer part of the health team that does most are Community Health workers. What was interesting about this is all of our Health Extension coordinators train Community Health workers. Its until the Affordable Care act. What were finding is managed care has these up. They pay us to train and deploy them. They are decreasing substantially hospitalizations er visits, unbridled use of medication. They are doing a lot of person training how to use the system better and addressing social determinant like transportation and other issues. So that is a growing concern. And finally, what is most interesting to make it come back and get there again. Instead of just stealing cooperative extension name running away and putting in health. We are now working with cooperative extension. I have interesting in the former panelist talking about the need for outreach and informing populations about how important it is to get insurance whether its medicaid or subsidized through the exchange. As it turns out, we just got the states grant to do that work with cooperative extension. Theyre in every county. Were in every county. Together were sending messages out. Its not just for the new people who are now going to become eligible because of the Affordable Care act. Its because 30 of the current uninsured people in our state who are eligible for medicaid arent on medicaid. There are so many barriers we have to work with the population as well. And then in our Primary Care Clinics, that are so separate desperate for the chronic disease patient to have, for example, nutrition education. Cooperative extension is now helping our Primary Care Clinic nutrition classes helping them grow food. We have bees going. They are selling automatic kinds of products. They are doing Economic Development around the primary care clink. Most of the federally qualified Health Center. I think theres a model that is developing that we would love to share. Thank you. Thank you very much, art. By the way, what are omsa that was listed under Economic Development . You can see them. Its the one with the tag on it. They are kind of clay pots. They are porous. Its an ancient irrigation. Its a narrow neck. You tick stick in the ground. Iter grate irrigates about a foot around. You grow little plants. 10. [laughter] great. Thank you very. Our final speaker is lisa miller. A Senior Program officer for the foundation a foundation in the state of maine. Hes a former multiterm member of the maine legislator where she was a member of the both health and spending committees. If you have ever listened to the alliances former honorary cochairman talk about oral health issue. You know how rural maine is. Were pleased you are able to join us today, lisa. Thank you very much, ed. I hope you can see me way back there. If i stand up it wont make any difference. [laughter] ive been brought here, i think, to be a little bit more on the ground aboutho expansion of coverage meets work force constraint in a small rural state. Let me give you a quickie little background on me. The census has recently said that we are the third most rural state in the country. We are now the oldest state in the country. I live in the oldest county in the oldest state in the country. We have been fairly lowincome for a number of years. We have moved clawing our way up from about 35th in personal income to about 28th now. These are not all great component that are going to predict good health access. Actually according to the United Health foundation in their state rankings maine is ranked number nine as a healthiest state. And if youre familiar with those Health Rankings, terrorist like 20 24 component to those. You know that your penetration of primary care one of the factors and rate uninsured is one of the factors and maine is very good on both of those along with the low violence rate and hue immunization rate,th. But the health of our Health Care System is an important factor in the health of our state as well. In fact, our Health Care Sector is the largest in the nation. That is Health Sector employment as a percent able of statewide employment. Wow, little maine. Why would that be . When you look at the graph of other state, you see the other states clustering up there with us are vermont, New Hampshire, west virginia, all small rural states, all significantly aging population. We seem to need bigger Health Care System for that kind of state. We join our other state colleagues in new england as having a very high penetration of primary care in that Health Care Services system. Maine has 1. 5 my primary care physicians. Its 1. 2. That sounds great. In any one time, any snap shop you take in term of recruitment. I cruised to recruit physician for rural Health Centers, were looking for 100 primary care docs all the time. By the way, my material in the back on the righthand side of your packet. I opted not to be very techy in term of throwing up slides at you. With that very generous, somewhat rich medicaid coverage system, we did not experience crisis and emergency issues around, do we have enough work force to deal with that . Were not as worried about what the aca and its expansion is going to mean in our little rural state. Now, since that time in 2010 when we hit the peak in medicaid coverage, it was rolled back, we have a conservative governor, we had a Republican Senate and house a few years ago, and they rolled back medicaid a fair amount. We will not be a Medicaid Expansion state. Our Current Senate and house, which is democrat passed Medicaid Expansion, the governor vetoed it, and we were not able to override the veto. We will not be joining others in Medicaid Expansion just yet. We will be watching New Hampshire very carefully. Maine seems to like to follow New Hampshire. New hampshires doing get another legislative study. Any of you, yall know, youre pretty much policy geeks. You know legislative studies are the fall back when you cant get anything passed. New hampshire is studying the impact of Medicaid Expansion on their state, and maine is watching, i think, somewhat carefully. What do we have in place in terms of production of primary care cle in addition, and how are they distributing around the state . We had a medical school for 35 years, and if youre at all familiar with the medical schools, they train primarily primary care doctors or have historically. 60 of the graduates have been university of new england in maine are primary care physicians. 25 of our rural docs are graduates from une so that is a very important resource to us. They are virtually doubling the class by 2015. Thats good for the work force. We started a new path program, never had an md Training Program in maine. Its a collaboration between tough medical school and one of our large hospitals. I work for a foundation. Weve been pumping money into that program. It is targeted at primary care. It is targeted at rural experiences in rural Health Centers and residencies in rural areas to get the young people hooked on rural practice. We have had a physician, a pa program, in maine for about, i think, 20plus years. We crank out 45 of those graduates. They will be expanding that program with funds from the aca. We have five advanced practice nurse Training Programs, and theyve hit a wall in terms of any expansions, and those of you who know about training, Health Professions training know the nurses are having a hard time finding enough faculty in all of their Training Programs so they are tweaking what they can. They are aiming at being oriented, a good thing for a state like ours. I would like to oh pine a little bit on will pas and Nurse Practitioners solve the problem . I dont think they will in maine. Over all the years in training weve done in pas and Nurse Practitioners, they cluster in group practices, going to suburban and urban practices like other clinicians. They go where theres good opportunities, good salaries, collegial surroundings. I just calledded our main board of nursing the other day and asked how many Nurse Practitioners set up a shingle by themselves in a rural area . Maybe five. That is with one of the most liberal nurse practice acts in the country. Were one of the top 14 states so even if you liberalize your practice acts, thats not sending, i think, you know, waves of clinicians out to rural areas. Theres more to it than that. What other things are we doing to shore up primary care in maine . We are grant writers, always have been. We have jumped on whatever foundation and federal moneys we can get. We have a very healthy patient centered medical home system in maine, a hundred practices. We are aiming towards 80 health home practices, Behavioral Health home practice the funded through medicaid and the aca. We have 14 of the Health Centers in a payment reform grant from cms, and, ironically, our state, which is not has not opted to set up its own exchange, has not opted to expand medicaid, low and behold, did opt to get a 33 million award for state innovation models from cms, and it has many moving parts in it, but some important moving parts will be shoring up primary care and tinkering with payment reform systems. Lastly, i didnt throw it on the stheet, but another important part of what is shoring up our systems in maine is that hospitals are buying up primary care practices right and left. About 7075 of the clinicians are owned by hospitals now, and that is mostly primary care. The thing that i worry about with that is that rural Health Centers, fqhcs are not bought up, and their salaries are much lower than the hospital based clinicians, and how do we keep recruiting docs and practitioners when salaries are so very different . To me, the ultimate access tool that will improve access in rural areas is payment reform. Tech tonic change in reimbursement, mostly between primary care and specialty practice. Thank you. Thats terrific. Thank you so much, lisa. Very impressive list of accomplishments in the state, and you had a lot of challenges remaining. Now we get to the point where were asking you to be part of the dialogue. I also encourage any of our panelists who have either a question for one of their fellow panelists or a comment on something that theyve heard to signal that and well try to catch that fairly quickly. We have microphones. If you do want to ask a question, in your own voice, go to the microphone, identify yourself, if you would, and keep the question as brief as you possibly can so we can explore as many of the issues as we can. Zane, let me reiterate my encouragement that you chiming in with questions and comments at any point. Of course, if you have a question you want to write down on the green card in your pact, thats fine too, and well have it brought forward. Let me start off by kind of tieing together some of the things that weve heard from several of our panelists, and it was triggered in my mind first when i looked at keith muellers map of where the aco spread is in this country, and although you make the point that there are what, 17 of the Rural Counties have some sort of aco presence, okay, six out of seven do not, and they look like an awful lot of aco deserts in what look like some of the rural states, and if payment reform is part of the answer, and acos are one of the ways we move away from feeforservice, is it important to try to get acos to move more aggressively and so some of the areas that were concerned about, and if so, how do we do that . Great question. Excuse me. It is important to get payment reform in the move to pay for value to be a higher percentage of higher value than volume. General movement is critical and needs to occur almost everywhere. If you look at the map, there are places in northern montana, places in wyoming where, no, because its just, you dont have the volume to make anything else work other than sustaining the feeforservice environment thats there. It may not always be the aco shared savings model. There are other models demonstrated under the innovation grants from ccmi, other models tried by major insurance carriers like in our state, wellmark, and they all have that theme, though, of trying to do two things. One, set up a Payment System that rewards high value and moves providers to even higher levels of value, and, second, sets up payments in which providers benefit from lowering the total cost of care, and, in fact, in some places now, its called a toe call total cost of care approach of how you pay providers. Uhhuh, okay. Anybody else . Yes, go ahead. Thanks. Bob rore, bmj. Two questions for you. First of all, how do health outcomes, how does, you know, the life expectancy, ect. , of rural versus urban populations difference . We heard, lets face it, were interested in outcomes. Whats the baseline difference the two population in terms of the Overall Health . There have been studies in the last year looking at mortality and it being low, you know, people die younger in rural than they do in urban areas, and a new Study Released in the last couple weeks from the university of pennsylvania looked at what drives death rates, rural verse urban, and findings are interesting. In urban, more likely to die in terms of a violent act, but rural is a higher accident rate relating to infrastructure and Emergency Care and things like that. Some of the chronic disease leads to some of that lower mortality rate in rural areas. There are studies out there. How that factors into outcomes, thats the outcome people are trying to figure out, what measures are relevant enough in the spectrum that you could potentially tie them to position reimbursement or hospital reimburressment. Theres the steps with the value based modifiers, but its not something to turn a switch on and do right away, but its the point of emphasis, i think, moving forward. The population data you talked about, which releasedded by the center for Disease Control and prfs, about, i think its eight to ten years ago now. I know that the university of south carolinas Research Center is working on an update of that, but its not out yet. Well, what about incidents of chronic conditions between the two populations . How do those differ . Higher in rural than in urban for almost all of them. Theres about a half dozen that people tend to look at . Diabetes, congestive heart failure, ami. You have higher rates of activity of daily living, limitations on rural populations, recovery from stroke, things like that, all part of that spectrum. Does that differ significantly by region of the country . I think so. Certainly, i think youll see a different gradient in the southeast than you do in maine. That correlates a lot of times with what you see with the Health Rankings too. In the regional variations, both urban and rural . Okay. Finally, talking about poverty in the definition of that, does that is that just based upon cash income . Rural populations can sub subsie income of growing their own food, which urban populations often do not have. You have 35 states that are so hostile they refuse to set up their own state exchanges so hhs has to come in and set up a state exchange, operate in those states. Im curious how you all see this enrolement process unrolling in the states, especially given the blatant political hostility at the state and local level. We have a related question, actually, that just came in on the cards, wondering whether, given the fact there are so many federally operated exchanges in rural states, how well equipped the feds are going to be to adapt to the local needs that are sometimes a little different in Rural Communities. We were musing about this last night at dinner, and i think certainly maine texas the maine the more we can call these products Something Else besides obamacare, the aca, whatever, the better all well be. The polls say, when you talk to people about what these Insurance Products will look like and the benefits theyre all for them. So, politically separating the names from it. Secondly, this i work for philanthropy, and that world is particularly the conversion foundations, foundations created by the sale of anthems, blue crosses, blue shields, hospital systems, whatever, Whose Mission is access to health care. Youre going to be fining states with very healthy conversion foundations for philanthropy theyre putting a lot of money into enrollment strategies with both public and private sectors. I think that is the factor that none of us really counted on before when we were thinking about the gearing up on this system. One thing, in the last couple of days the department issued their agreements with web brokers and what role do you all see web brokers playing in the process . Many of these web brokers are licensed as agent brokers in the states and, therefore, avoiding conflicts and issues about navigatorsorsorsors and whether navigators needed to be licensed and in states that are hostile to the implementation. What do you see web brokers playing in this reason this enrollment process and why that this not been talk about more at the state level . I can speak for new mexico. The current brokers are not allowed to serve as navigators. They have to be trained separately. They cant have the kinds of relationships they have had with insurance companies. They have to be neutral. The problem we have is that you can have as many navigators as you want. Each time you navigator, like a worker, spends hours with an individual to try get them, either on the exchange or medicaid, that doesnt deal with the fact that 80 of the population in new mexico, who is uninsured, doesnt know about what the availability is, and its part of what you said, about the hostility of the Political Climate that has so tainted this. But there are other ways, like you heard of suppression of votes. Theres also suppression of getting people enrolled. There are so many barriers to someone becoming enrolled, whether its stigma or distance in a rural area or, they lost their application, or, we didnt hire enough people in the Medicaid Office to many it. Just have to wait. There are so many ways that even a state that has accepted medicaid can slow the process, with many people having a view of medicaid as its a handout, just making people dependent. That is the hugest problem were facing in our state, which has accepted medicaid. Okay. My name is sandra wilson. And i work for senator in new mexico. My question is directed to you and others as well but im interested in the issue of social determinens of health and intervening early, and we think about health Delivery Systems that are coming. Are we addressing that level of intervention and if not what should we doing federally and is there anythinging but out there to address this . If you were to make one intervention that would make a bigger impact on health it would get more kid graduating from school. The problem is its a different system show. Health system uses its money we have to figure out a way to cross sectors of the community. One way is from, pipeline into health careers. My feeling is its great if they went to become a nurse but even more important they graduate from school. So we have to use the Resources Available to understand the impact on health of these other social determinants. Were setting up food pantries around the state, in food deserts, in our rural area. The third highest feud insecure state because its a health issue. In hospitals im doing drips. Theres a disconnect how im being paid and what communities need. So in eave one of these major social determinants, the Health System has to be these bridge people like Community Health workers are so important. Theyre bringing this reality into the front line of our clinics and hospitals and it has to be ramped up. Ill jump in really quick since theyre own there buzzing. Another thing we are doing and maine again, work for philanthropy that is very interested in primary prevention weapon started looking into how to prevent domestic violence. What you do is many steps back and look at the field of early Adverse Childhood Experiences and hoe how predictive, if you have been exposed as a child to drunk date, domestic abuse, loss of a parent, extreme poverty, the tack tracking of your disease, not to speak of the social problem you may experience, is dramatic. So were now in our state we have a very large effort at looking at Early Childhood enter enter intervention, helping professionals across education and Health Sectors to be looking for Adverse Childhood Experiences and intervening because they have huge health implications, and can lead to complications later in life. The Public Health trust fund that was in title 4 of the aca has been funding some Community Transition grants around the country so if you looked up through a search engine, Community Transition grant youll find examples. Some of the innovation grants funded out of the center for medicare and Medicaid Innovation include transitioning, and theres a Large Program that the Johnson Foundation has been supporting. But any of those sites you can pull down specific examples. One thing to add and that is the Community Transformation grant that keith mentioned had a 20 rural setaside in it. The first time in my 17 years there was a real set aside and there was a recognition of the fact when you block those things to at the state it tens to be, where can you get the biggest impact for the number and that often is in the urban and suburban areas so when they said specifically 20 of the funds needs to go to the rural asibl aees is an path forward how to address the fact that disease states are worse in Rural Communities and earmarking money for that and acknowledging it on the front end in order to change outcomes. Sifting through a bunch of green card. What have you come up with . In speaking with lisa and the questions that have come up in the types of delivery best done locally with the federally qualified Health Center, theyre a question asking you mentioned the expression of fqhcs as increasing access to medical care in rural areas. The expansion has not been as robust as planned in aca due to a cut in the discretionary funding funding in 2011, causing the cac fun to backfill for the cut. If the expansion had gone through what would the impact havin rural glairs and i think you both discuss that, and time your were talking about the funding mechanisms. If you could both address that. I think its hard to predict for dollars that arent there because there are competitive applications, so i think you could assume that some of the funned applications might have been from rural areas but its hard to look back and say it would have been this number in subunder barn and another number in rural. But look can back too the bush folks and their expansion we have an dramatic increase and we saw them in the rural areas and but not in the mid10990s. You discussed the deficit production proposal caused changes with the rhc and cr access to hospital changes. What were those particularly . Proposals about whether the mileage standard should be changed for critical access hospital which have to be 35 miles from another hospital, and provision allows some to be excepted from the mileage requirement. So there are some 55 that are ten miles from the hospital. So, the congress has proposedded to take that away. In other words, lose the designation for the ten miles or less, and what i addressed was the Committee Looked at the impact of that on what it would mean, and then there have been myriad proposals, eliminating medicaid dependent hospitals in a community. They were saying i if you do this, this is the result in terms of savings. None of to the proposals were acted on. Theres just proposals at this point. Very quickly, maine jumped on the potential to expand Community Health centers during the bush administration, and i think we did as much expansion as we could support. I worry now, if we expand many more Health Centers, whether we can recruit the staff for them, and also the development of atps and most of you who saw this map, maine looked really good. It was covered. We do have acos deathing and what is interesting is they can dont be seem to be talking to fqhcs because its a different system. So expanding to maine worries me if the behemoth is going to be an acl in the future. Al, am media. Do any of you identify any further significance, emergency room and ambulance services, changes . Changes due to what . You mean future present and future maybe what you foresee possibly, too. Well, can i jump in . Please. Go ahead. We did a recent study in maine because our er use is very high. In rural areas its very high. The number one visit for ers, particularly among medicaid, was for dental and oral health care. So, were not solving that with the aca. Theres some improvement. But these systems remain very polarized not polarize do nor separate. We have our behavioral care system moving closer to primary care but oral health is still out there and they arent integrated. I talked to aco people, are you going to include oral health . Oh, no, we dont do that. Well, how are you going to impact your er visits in so, we i don dont know if other states have seen that but theres a lot of interplay between oral health and primary care in the er, and right now the aca is not covering that. Theres a real conflict thats going on now where some hospitals dont want to see the er visits go down. Thats how they fill their beds. And so in that regard, some of our strongest partners doing the most innovative work for prevention are actually the managed Care Organizations who save money by decreasing er visits. When i have gone to hospitalled a administrators we talk about nurse advice lines, and i asked the hospital, would you like to pay into this . He said youre glowing to decrease er visits . Why would i support that. So near a transition of incentives and the more patients they receive more money, on the other hand if we can cut down the number of people seeking care, we save mow, and until thats resolved and were in this transition, were going to have this pull and tug. Part of the followup, there was another question here and i think it fills in with this. First of all, with lisa, the direction of the dental provider in maine, and theres a question asking if you can speak to how the efforts in maine to authorize a new type of dental provider to go into the underserved area, and the same discussion is how i know we talked about is earlier but also including the role of pharmacists in supporting chronic illness management and rusk through health and wellness reforms. Both questions are the discussion we have had about using other options of types of folks to help provide the care. I feel that pharmacists are the most highly trained, underutilized members of the healthcare team. The dilemma is the money they nick Retail Pharmacy far exceeds what they can make providing patient care there is a movement continue crease clinical pharmacists. Theyre trained this we but the jobs and residencies are not there for that. But when you look at their role managing most difficult debris diabetics, theyre incredible. Were so reliable on them. If you go to in community who can you say day or night for free . Its only the pharmacist. They will give you ideas. Go to aisle 6. Butout cant do that with a doctor. Its three months for a wait, unless you go to the er so the fortunately mist is the pharmacist is moving rapidly but to overcome barriers i mentioned. Im matt with the States Alliance for balanced insurance regulation, and the dove tails with the last response in terms of a changing the way we utilize different Healthcare Delivery professionalses. Wonder if anybody can comment on the current reimbursement status of telehealth and telemedicine after the Affordable Care act and how thaw could potentially impact some of the challenges unique too to ruralhawkhawk Rural Health Care communities. Theres a report about telehealth, and it addresses a lot of the reimbursement issues. The aca didnt change anything about the way teleHealth Services are paid for. It remains the way it has for the last couple years. Medicare covers a small range of services, state Medicaid Programs cover more. Theres actually a resource god out there that catalogues the 50 states in which Medicaid Programs cover. Private insurers have not stepped up much outside of closed systems such as kaiser. The biggest innovation is what is going on in the va. And we talked about as you talk about aco and shared savings and focus more on the outcome and less on site of service delivery, telehealth may be a national fit with where health care is going and where its been where the concern is on volume and the payment for that particular service. Some of the Healthcare Systems and organizations may be our early adopters of telehealth because it works with management of patients and other. Making care more accessible, one example being telehealth in an emergency room and you bring a boardcertified physician into the virtual presence of the er that starts out with a Nurse Practitioner or pa on the site at the time. And if the payment support behind that is again, the physicians and organizations are accepting plame contracts that are global in nature or theyre participating in some sort of shared savings arrange. And by lowering the overall cause through the use of telehealth, even though theyre not getting paid directly farthel Health Service, theyre the teleHealth Service theyre receiving a benefit. I dont want to put zane on the spot because i dont know if this is your expertise, but seems to me that private organizations getting Global Payments as keith was talking about, are in a position to use those payments in the most efficient way, including telehealth, and i wonder if that it something you have been pursuing. We utilize telehealth in many of our markets. As you stated were on a global payment schedule. We just have to treat the whole person, and we have to find the right care, right place, right time, and so if telehealth is one of the best practices that we can utilize and bring to the table at that time and use, thats part of the schedule of how we serve the patients and as far as we have contracts and we have otherwise further services but certainly part of the considerations that we take in when were looking at them. Yes, sir. A familiar face. You mentioned trying to find physicians, pharmacists. But the direction is in the opposite direction from payers, she switch to centralized filling of prescriptions, mailing of drugs, giving incentives to patients to use this because its more cost eeffective rather than use the local pharmacist. How are you seeing these forces play out between what youd like to do to make better use of these providers and the economic forces that are pushing towards a more centralized and nonaccessible use of pharmacists. To me pharmacists are very, very highly trained. A lot of what they do in Retail Pharmacy can be done by farm pharm techs. The problem is some states require the pharmacist to be there dispensing so one is you could have a pharmacist and thats what were now developing in new mexico where a tech can disexpense but the telehealth where the pharmacist can look at the prescription and youre keeping them open. The second is that 52 of prescriptions in the United States are not filled. So, primary care, we write prescriptions and dont know until the patients come bam with diabetes out of control they didnt fill the medicine. So pharmacist are taking roles in actually monitoring and informing the prescribing doctor when a patient doesnt pick up a prescription. When you start to see how they could be used, and with chronic care, going of the detail with patients about that role. So i think its something that is coming. Youre absolutely right. Right now everything is volume. But i dont think thats what is going to improve the health very much. It does improve access for pharmaceuticals but thats not the big intervention that has to happen. So every Pharmacy School is trying to figure out how to get more of the graduates with clinical pharmacy certification and then finding through the reimbursement that is currently changing with the aca, how they been part of teams, just like with other healthcare providers. Actually, that raises a related question, it seems to me. Part of the way youre going to be able to use the pharmacist expertise is or the dat that comes from that, is to be able to tap into data sources that will tell you the 52 are not being filled and that in turns leads me to question something that was referred to earlier and that is, the collection of data in rural areas, visavis urban areas, questions like, Internet Access and sufficient Health Information technology that are maybe as a little more of a challenge in some of the rural areas, and i wonder what our panelists might aufner the might offer in the way of observations there. Ill start reflecting on experiences in nebraska where i was until three years ago, and now iowa. The technology is less and less any kind of barrier, both in terms of the spread of access to broadband capabilities and capacities. Theres still some gaps out there, but they have shrunk considerably, and there are still some pockets of Financial Assistance available to help install the technology. The usda or through hhs at the federal level and a couple of Major National foundations still investing in chance of broadband capacity. The larger barriers are related to the incentive for the local provider, particularly if you move out to the small rural clinic or the small rural hospital, what is their incentive for taking the personalliner in time and investment required to install the system and learn how to use the system, and what is the operational tradeoff when theyre investing in that same capacity, both human and capital, over time. Those alignments havent fallen into place yet. The Meaningful Use Incentive Program that was in the legislation that was part of the recovery act has made a big difference. There a lot of dish was just visiting in another state some rural practices for a research project, and one of my concludes that surprised me a bit was every single one of them was in a meaningful use classification and these were relatively small rural primary carry practices. So that kind of Incentive Program in their area was an active system, has made a difference and moved them forward. Can i Say Something real quick . Heres the real practical incentive in maine. Hospitals are not going to buy your practice if youre not willing to move into computeunderbased patient records, computerbased patient records, and thats practically is happening in maine, and the hospitals are buying them. The fqhcs have been computerbased their claim for a long time and now the patient system. So the reluctant rural practitioners in maine will be retiring soon, i think, and we are very data rich state. We have had we have all pair systems in the country, one of leading Health Patient information exchanges and were now trying to merge them. So in a tiny rural state like maine, its going to be even mere important to access information through a computer. So its inevitable in our state. Got a question for tom morris. What role does do the play in payment for providers in medicare. I should ask what role would you like to play . The first part rather than the second. The role we play is we review all the regulations as theyre developed each year. So, were not a so much in a situation where were setting it. What we are looking at, as we think about how its constructed, with the condition of the patient regulates payments, the provider has too meet. Are those taking or unique rural circumstances. Those are the sort of things we are trying to do, to make sure its a level playing field. It can play out in a variety of different ways. For instance, they may transition a certain payment because it has a negative impact on a certain provider class, instead of doing the whole reduction in one year, they may space it out over five years to give people time to adapt to it. On the condition of the patient side they look at somebody may income a Perfect World you want somebody with an mba to run a home health agencys Business Office and that may make perfect sense sitting in an office here in washington but may not make sense in a rural everywherey somebody has didnt doing the john for ten years and only have a associate degree and theyre doing a fine job. So were privating privating pr providing the rural lens, is it needed, is it fair, and what were trying to do with that particular regulation. Theres been a discussion with regard to a lot of primary care. The question asks to expand that, and i think dr. Kaufman in a prior conversation, this is something you might have addressed. Can you speak to the impact of access to mental Health Services in rural areas. 40 of what we see in primary care is behavioralhealth related 40. of discharges from the hospital are related to alcohol and substance abuse, and of all the high utilizers, 70 of the underlying causes of those hospital discharges, of those high useres, are Behavioral Health. In 70 of that, is alcohol and substance abuse. So the question is oh, do you get alcohol and substance buoy and Behavioral Health treatments into underserved areas. Back to our telehealth discussionsment one of our booming needs and resource is telepsychiatrists. I dont want to keep saying cooperative extension is everything but its everything. I couldnt believe it. As part of our collaboration with them, their family Consumer Science is actually train family counselors all over the state. They need to work more with supervision so were have something of our psychiatrists do supervision with. The its just another way of trying to increase resources. Its not going to come through enough psychiatrists. It has to be other kinds of counselors, licensed social workers, and this Mental Health first aid can have a substantial impact. So you have to step back and look what is available, who is there, and how to train that resource when you have more technical difficult problems you have to use telehealth. Unfortunately in new mexico, theres so few places they can send someone who is very ill. Those doors are closed. And then we leave Community Hospitals with this very, very difficult patient to care for. The families are stressed. They have no place to go. So we have to accept this as a burden that we take on, not just them. Its very easy to say, im sorry about that. We cant do that anymore. Before you ask your question, might say between us, sean and cain i have enough green cards to last through the weekend. Were not going through the weekend so if youre really absolutely dead set on getting your question address bid the panel, commend the microphone to you. Just retired from 33 years of one of the 40,000 National Health corps people who stayed in their community, and im impressed with your retention number. I was in rural east tennessee and the thing at the same time pressed me the most is people who came and left in two years, which decreased the reliance on those types of people because they didnt really want to have someone who just came for the short period of time. Im wonder, its good what youre doing with the start term, there is something we short term. There is something we can do earlier to address redefining rural practice as something that will be i dont want to use the word supported but that you will get some sort of ongoing recognition that this is a very Important Role to have. One of the things that lisa brought it was that at the acos develop there will be fewer and fewer people where i was working at, Community Health center, and these issues around telemedicine, if theres no one out there to turn on the tv, you dont have anything. So, im here to say that its very, very important that we work on this retention and we work earlier and we identify to all those young doctors who are going to primary care medical schools that there really is something there because most of them are graduating fewer than 10 of people who go into primary care. Thank you. Let me just add something. What you said is so important. We looked at the dat over the last 30 year if you come from rural yeah, youre six times as likely to go to a rural area. But to do that you have to change your admissions procedures procedures to all the Health Professions and thats tough. But were changing that. The second is, if youre from an ethnic minority in our state, your likelihood is even higher, and youve trained, come and graduated from Nursing School our state and you went to college and medical school its even higher. So were putting those factors in to try to change this whole notion of who were taking in. Its not how were going to loo good on u. S. News and World Reports and high scores. Its do we get graduates where theyre needed around the state . The second is, where they train and how you support those sites, like the Service Corps sites. Were finding if you i can them more academic unit the center of traininges is decentralized. Were finding for the National Service corps, fqhcs, theyre desirable even though the payment is lower because it addresses what graduate are doing to serve the community. Im from new mexico. Did you meet i have a followup. Part of her question was also about what incentives might there be for the short term as well. Thats the longterm goal, getting the graduates into practice and the rural areas. What can we do to get incentivize the hospitals that are actually hiring the providers to participate in that practice . Certainly in the short term, i think rural clinicianses have to bite the bullet and decide that teaching and training is also part of their responsibility, and if i live with a rural physician. Theres a lot of whining about life is so hard, but, guess what . He was an urban child who had a rural Health Center experience at uc san diego, and he lives in a town of 500 people now and practices in a rural Health Center there was something magical about that experience in rural San Diego County that flipped him, and those experience are very, very important, and i think rural practices and rural hospitals and larger Community Hospitals have got to be very purposeful about preparing clinicianses to be teachers as well in those settings, to unveil and portray the wonderful life and imbeddedness in community. If youre seeking community you need to be a rural physician. In nebraska where i was previously. The state has highly successful Pipeline Program that brings these pieces together, starting with introducing the sciences to elementary age students so the university sponsors an eighth grade science fair, all the way through admissions policies that favor people that come from rural places, shortening the length of time that it takes for them to go from entering the undergraduate college to completing their medical training, including rural residence training tracks during the undergraduate and then residencies, and been at it long enough we were beginning to seal the data of the eighth grade science fair students who are now practicing clinicians, and theres some data that says this increases the prospect. But combining them all into a subject Pipeline Program, adding in Element Office loan remain, is sort of the sweet spot we should be looking for. Said it nicely but work force is not a federal responsibility and its not a state responsibility. Its a shared responsibility, and also includes local communities and so that continuum of activities is really critical. And there are pockets full of states and programs that have figure out. Just not enough of them. Our last question referred back to something lisa was saying and that is that fqhcs are finding themselves a little behind the curve in being acquired, anyway in what looks like the coming wave of consolidation. I wonder if that is more generally true across the country, to your knowledge . Or is it something that is unique to certain specific areas . Well, one thing i might add, fqhcs cover an important part of the state, and theyre both paid differently than we pay physician practices, and thats a good thing because its a recognition that been in place for 25 years they needed costbased reimburse independent tornado get providers to provide access to care. But these new models we have had to figure out how to blend people who bay 0 on a fee for service base basis in a costbased environment and its very difficult, and as a result of that, thats where are you sew the issues suzanne was referring to. Its hard to bring them into the loop but folks are figuring out workaround, moving to second Payment System. And things are going to get better but its been a built of a challenge. On web site you can see some data about how many critical access hospitals, fqhcs and rhcs senior participating in acos. The numbers are small but their that. So we need to understand, how did that work for those acos and fqacs and can we spread that knowledge around more . The whole genre is still so new theres time and opportunity for those organizations to come together, but a lot of that is going to have to happen at the local level again, among the organizations. Its not something that a policy lever is going to make happen. Yes. , in. Im casey with the association of american medical colleges mitchell question my question is for dr. Mueller elm you mentioned briefly programs implemented in iowa to promote doctors practicing in rural areas, specifically from medical schools. Can you mention more about that and what impact they have had so far . In iowa there are two things that have occurred. One is the pipeline from my previous time in nebraska in iowa there are two particular initiatives that are very new. One of those is a loan repayment and incentive initiative that the governor promoted this year in the legislature enacted. So theres some state resources being devoted to incentives to get Healthcare Professionals to distributes more across the state, and the ice from the university of iowas medical college, which crated createa Loan Repayment Program for its participants who serve in rural areas. Theyre pretty new so i dont have a lot of evidence, like iodamide nebraska where the program has been in place in nebraska its a full pipeline that starts with activities at Elementary School and goes through the admissions process, education and residency. We have only about five minutes. So, i would ask you as we go through this last q a or two, to pull out those blue evaluation forms and fill them out as you listen. Yes, you may have the last question here. Yay. I was just wondering what some of the Biggest Challenges you find are with the Biggest Challenges you guys face. I wonder if you could say that again a little more closely to the microopinion. Im wondering what you think the Biggest Challenges for Childrens Health in particular are in rural areas . Okay. Poverty. Plain and simple. The rise in poverty among children in maine is pretty astounding. And im not entirely certain why but the recession has not helped. It just stands out to me all by itself. I would add, i absolutely agree. If a parent is uninsured, that child who has medicaid gets too to 25 less care because the parents are not connected to a system. And the stress the parents are under affects children in our state we have a very large undocumented population, and that is not covered by any of the aca or any other theres a constant struggle. Theyre a vital part of our economy and most of the kids were born in the United States, have medicaid, but their parents are being threatened with being imported so the stress level is extremely high. The other is an agedependent issue. Most family docs, pete tricks, see children. When youre a teenager, you wants to see a doctor . You have to set up School Clinics and go where they are because theyre going to keep airplane from you as much as they can, and yet the needs and transitionses are so high at that point. Zane, a final question for us . Possibly two that to dig a little deeper. Access and navigation to care is one of the largest problems in the childrenbased population. With that you have schoolbased center. New mexico ute lies schoolbased heck economic how do you view that, getting back into some of the questions about screening and the followup care . Because screening is a detection but what do you do to make certain you get access to care. We have one of the highest rates of schoolbased clinics in the state and started with students and residents and then they set up their own clinics and we found when we polled all the providerswhats the number one problem in teen health, for example. They said its teen pregnancy but we asked the kid, but their number one issue was feeling social exclusion. Theres a nothing is as bad as being excluded from a group thats a fate worse than death. And so they were dealing with behavioral issues and we had to change the nature of what we did in those schools. Oh, yeah, we did a little behavioral we had to go into classrooms and do a lot of counseling, brought in our other counselors because thats the real issue, and its closer to what the real risks are for those families and then dealing with the local families. So the whole nature of the School Health programs provide has changed. Well, i think we have covered a lot of ground. We have left a lot of ground to be covered. But i want to thank you for some wonderful questions, including the onessed we didnt get chance to address. Thanks to our colleagues for participating in and helping support this briefing. And thank our panel for a wideranging discussion and ask you to help me thank enemy the appropriate manner. [applause] consider thats telethon like plea to helpes reach our 50 return evaluation goal. [inaudible conversations] s [inaudible conversations] this is a web site, the history of Popular Culture. A collection of stories on the history of Popular Culture, and to say pop culture, its quite more than that. I think theyre what ive been trying to do with the site is go into more detail with how Popular Culture impacts the politics and sports and other arenas. Not just about pop culture. What we have on the site are stories about popular music, we have sports biography. We have some host of media entities, newspaper history. So there are a range of things. And when i formulated the site, i purposely cast a wide net to see what would work. The first lady reflects the schism in the United States about what women are supposed to be today. Are we supposed to be mom in chief . Or first mate . And so to navigate that if the president is supposed to be head of state and head of government, is the first lady supposed to be the ideal fashionista . Supposed to be mom in chief . Supposed to be first help mate . But at the same time, if she is going to be first help mate, that means she has to understand what is going on in the administration. She has to understand what is going on in the country. And she has to understand her husbands political agenda. So, you cant really separate, i think, how the first lady presents herself and the conflicting expectations that the country still has for working wifes and working mothers. Next, a discussion on the Obama Administrations Economic Policy and their effect on certain sectors of the u. S. Economy. Thes an hour and a half. Were also joined this morning by heidi schierholtz. An economist at the Economic Policy institute, and then very veronica. Want to get your perspective on the economic of the Obama Administration. President obama today at a florida port vowed to speed shipping and talking about how he can boost the economy. Lets start out withsome background. Whats the state of the economy now . How do you judge the economy to date . I think its too weak. Weve been out of the recession for four years. I think that the best way to describe it is like the labor market is stuck in the mud. The Unemployment Rate, which is the share of the population that is employed, has been almost flat, and very low. As Unemployment Rate has again down and thats because 0 lot of people have given up working, and Economic Growth is not as strong as it should be to hit get all these longterm unman employed people back to work. I its disconcerting. I completely agree. What we saw you look over the last six years, during the great recession, our labor markets fell off a cliff, and since that time, since the recovery began, we have basically just been bumping along at the bottom of the hole. We havent really start climbing out of it. And as she mentioned, the Unemployment Rate itself actually has improved. Right now the Unemployment Rate is 7. 6 . That sounds like a big improvement from the peak of 10 in the fall of 2009, but the thing is that most of that improvement was due to people either dropping out of or never entering the labor force because of weak Job Opportunities. So when you look at broader measures of Job Opportunities, what you see is just really havent improved much since the recovery began. Theyre not deteriorating, not getting worse, but just not digging out of the hole very fast. Host were talking about the economic record of the Obama Administration. If you want to join the conversation. Heidi, point to some items and things that have been done that have impacted the economy, either for good or bad. A good question. The thing that is useful to think about whether something was the right thing to do, was to diagnosis what is wrong with the economy, and when you look at the dat, look at what is going on in the economy, the thing that is the problem is a lack of demand. Businesses we all know that businesses are sitting on a lot of cash right now. I dont necessarily think theyre greedy Business People not wanting to hire. Theyre actually smart Business People who will hire when they see demand for their goods and services pick up in a way that they need to hire people. Theyre not hiring because they dont have demand for their stuff at the degree where they need to put that factory back online and get more people on the floor. So thats the problem, a lack of demand. So what we need do in our economy to boost the recovery to dig us out of the hole, is to boost demand. So the things that a government usually has in its pocket to do that, Monetary Policy, thats the fed reducing Interest Rate to stimulate demand. That is defanged because Interest Rates are around zero. And the other is fiscal policy, stimulus. Congress did that. It was a great job in early 2009, passing the stimulus package. The problem is it was too small. It got spent out too soon, it was around 800 billion and was never enough going up against the 7 trillion housing bubble bursting. It was never enough to really get us into a robust recovery. Host give your perspective on what has been done by the Obama Administration and what has or has not worked . I have a slightly different understanding. I think funds are sitting in businesses are sitting on cash and consumers are being tim met, and timid and its not surprising considering the immense amount of wealth destroyed by i see a lot of the unwillingness to ask more as fear and uncertainty and a lot of that comes from actually a lot of Government Intervention which people dont know whats going to happen to them. Like i think theres a clear newspapering clear understanding we have a big problem with debt and deficit, on the to the it has slightly improved. But people understand that it probably means a lot of higher taxes in the future. A lot of big rules have been passed. Many of them havent been written yet. And people wonder what it means so they dont know what the world is going to be, how its going affect their businesses. So theres a lot of uncertainty in the economy, a lot triggered by Government Intervention, all done for intention for the most part. I actually think heidi said what government can do and Monetary Policy and fiscal policy. Youre right about Monetary Policy. I guess theres some debate about the fact that the fed could actually do better and more in targeting nominal gdp and things like this but fiscal policy is also made very weak in its ability to do something. Its been tried, and its been tried the Obama Administration made a lot of promises about what they could do and didnt deliver on the promises, and believe in the ability of fiscal policy to boost the economy. One things is its only effective in the short run, and you have been in this for a five years. When is the short run over . So i actually think the policies what they need to do is actually try to give free market a chance, try to streamline regulations so people can actually start hiring and people can take action. Lets take a listen to president obama yesterday in jacksonville, giving his own reflection on where we were five years ago and we we are now. The good news is that after near live in years since the financial crisis happened, thanks to the hard work and resilience of the American People, america has fought back. So, together we saved an auto industry, and i was told that the terminal i was at is one of the places where were sending out more american cars than ever before, all around the world. [applause] we took on a broken healthcare system. We invested in new American Technology to reverse our addiction to foreign oil. We doubled our production of clean energy. We put in place tough new rules on the big banks and the mortgage lenders and credit card idaho make sure we didnt have the same kind of financial shenanigans we have seen before. We changed the tax code. There were too skewed in favor of the wealthy. Made sure it was doing more for middle class and working class families. We flocked locked in tax cuts for 98 of americans and then asked the folks at the top to pay a little bit more. So you add this up and over the last 40 months our businesses have create 7. 2 million new jobs. [applause] 7. 2. And this year were off to our strongest private sector job growth since 1999. Strongest job growth in over a decade. Host we just heard from the president and heard only other panelist about her perspective what the government do do now and whats your response . One of the things that is employment being held back because of Business Concern over regulations or uncertainty over what policies are going to be put in place . We have way to test that. If that were true, and if business had demand for their goods and services but didnt want to hire because of uncertainty about future policy, they would be doing is ramp upping the hours of works they health increasing the hours of workers on staff. They dont want to hire new people but can meet demand through increasing hours. We have not seen that. The length of the average work week is no higher than it was before the recession began. So theres actually little evidence that businesses are holding back because of insertty or because of regulation. It comes down to they just dont have demand for their stuff. That means theyre going to need to hire more people. So thats where the issue is. So thats where we should be focusing our energy to get is out of the hole. Host lets hear from some of the callers. Anyway cabs nate, kansas city. Im tired of hearing about president obama. Because really what has gone on that i see and i do a lot of studying is that basically taking away government jobs and even a lot of factory worker jobs, and theyre privatizing so much government jobs. Just like in florida. Florida, come august 1st, all the medical people for the prisons, theyre going to be laid off. They can go put application in from the private contractors but cant guarantee them a job and i they do get a job, they get lower pay and they get also no pension. But the whole idea of what is dish challenge cspan, you need to do a segment on forget about the president. What a lot of the republicans not just republicans but mow e mostly republican goods theyre rung under the radar as far as contracting so much of the government out and so how do what that does, that makes a lot of people that is working today, wont be work tomorrow therapy. Privatizing the prescribes out now, and the prisons out now and the inmates are using theyre using the inmates to run the prison because they dont want to pay the personnel to run the prisons properly. So what is happening is were being undermined, this talk about the president is nothing compared to what the republican governors are doing in the legislature and stuff like that. Basically privatizing good jobs that people had for years. Host thanks for your input on looking at governors. Appreciate the thought you talked about government jobs. Heres some numbers from the treesy the treasury department. Looking at where growth is happening. The private sector is leading growth, and you can lead there private, nonfarm business, and then government right here, federal, state, local. What do you see when you look at where development and growth its happening . I think so the private sector has always the true engine of growth, Sustainable Growth and sustainable jobs. I think what makes thats an important question and that is the point that underemployment of the people who are employed and thats another problem with the labor switch and thats another sign that the Unemployment Rate doesnt capture everything it should capture. For instance, while we have people who are working now, and a lot of them are working in parttime jobs. More than before. So a lot of people actually would like to be working fulltime, arent, and thats a product of some regulation and in particular the aca, the health care. When you poll businesses theyll say that in order to get around that law, whether we think the law guess or bad, theyll hire parttime people which then compounds the problem of underemployment, even for people who are in a job, and thats a real problem. Host hid di . Theres a couple of things id like to respond to nate brought up a really good point about the loss of Public Sector jobs. In this row, weve lost nearly threequarters of a million Public Sector jobs and its a huge drag on the recovery. The other this when you lose a Public Sector job, there are also big ripples into the private sector. I estimate that for every Public Sector job loss, through rim effect into the private sector, theres a lot of one private sector job 0, or a private sector job that was not gained. So its a huge drag on the recovery and a drag that wasnt weighing on earlier recoveries. So just to put that in context, itself we had the same Government Spending now that we had in the recovery from the 2001 recession, in other words in the recovery that george bush was president during, if we had the same level of Government Spending as we had during the recovery we would likely have three million more jobs now. So the fact that the Government Spending is going down, rather than up, is a huge drag on this recovery. So it is a really good point there the other thing he talked about is contracting out of government services. Theres something that the president could do on that. The president could, through executive order, could just say that he talks about state and local but going to move it to federal spending right now. President through executive order could actually say that people who are employed by federal funds, people contractors who are employing people, subcontracts for people, they have to pay a living wage. They have to offer paid sick days. The president s action could make a lot of highjobs and have a big impact right now two Million People are paid in jobs less than 12 an hour through federal fund. Through this kind of crag. Contracting. That kind of executive order could have a big impact on employment quality. Host lets good to henry in oroville, california, republican. Caller in gordon. Good morning, cspan. Yeah, when he said the topic has changed, could talk all day on this one. But, yeah, i dont see any change. The healthcare i turning out to be major disaster, which is dragging the economy down. My feelings are im sort of what you call naturalist, and by the government sticking its nose into everything, trying to be big brother, whatever, theyve managed to what call natural selection, people making bad mistakes in business, they should lose. If the got feels they should bail them out. And the people in the upper part of it, they win. Everybody else loses. And so that seems to be the trend, and fortunately i work for a company that the management makes good decisions, and we are surviving but not surviving because we have had big brother looking over our shoulder. Host lets get a comment. Im glad he brought up the health care. What we actually see is that so far the evidence suggests that its e its not going do be implemented theres going to be bump inside the road but a that its parking pretty well. For example, new york, which came out, showing that premiums are going to be reduced by about half, when the aca, the obamacare is implement. So the signs that are coming out is that the insurance that people are going to be able to get, the insurance they have to get through the mandate, is actually going to be a reasonable cost. The implex addition looks like its going well. Theres been some flexibility in saying, okay, the employer mandate, the idea that theres going to be sanctions against employers, certain employers if they dont provide Health Insurance. The administration said theres some problems with that. Lets put that off a year. So theyre being flexible when things are looking like there might be bumps in the road. So its not perfect but all signs point its going to be successful implemented and will provide health tvs to mens of families. People with preexisting conditions who could not guest Health Insurance they could afford will know but able to. That is going to make our country stronger, going to be better for the people of this country, and looks like its working. I find that interesting that you should bring up new york because it is true that the study came out and showed an improvement, but its because new yorks Health Care Market was one of the most rigid. One of the least market oriented of the country, and so that it improved is good, but its unlike in fact all of the signs were getting, california, not such great news. Were getting signs a lot of the premiums are going to increase by gigantic amounts and i agree theres always bumps in the road, and implex addition but these are pretty big bumps. We have big bumps. Lets not forget the act which was supposed to be reducing the cost on the healthcare law had too be repealed because it was unworkable. And now the employer mandate its been delayed and theres a lot of people who think it is going to be permanently delayed because its unworkable, and one of the problems that the healthcare law was making was, first well, some of the problems, we were going to cover everyone. Looks like its not going to be the case. So for better or worse. I dont think covering everyone is necessarily the right direction. Certainly poor people need to have access to health care and be able to get Better Health outcomes, but the other one is people are going to be able to keep their insurance. Theres a lot of signs this is not going to happen. And finally, as premium goes down for everyone was one of the promises that was made, and its prium go down, butple, will see theres absolutely no doubt that, again, younger and healthier people, again, will have their short stick, the wont see Social Security and will have to pay for medicare, and will see their premium go up significantly. Im not as optimistic as you are. Host were looking at the economic situation, the Current Situation of the me and what president obama and his team at the white house have done for the economy over the last five years. The president in florida talked about in the infrastructure. The head libs he vows to speed shipping and transit projects, and you can see him touring right there in jacksonville, florida. Lets hear that the president had to say on infrastructure development. Theres a bipartisan bill in the senate to fund critical immigrant prompts in our highways and bridges, transits and rail systems, and our ports like this one. And so the house should act quickly on that bill. Lets get more americans back on the job, doing the work America Needs done. That will be good for middle class families. That will be good for middle class security. Lets get to jeff on the democratic line. Jeff, we were just talking about california. Go ahead. Caller the lady hat that does not support obamas healthcare plan, she probably really likes the plan before Obama Health Care was passed, which was insurance rates were skyrocketing, they were going up without the plan. So, why is she blaming obamas plan for skyrocketing rates . Its the big business that is manipulating the rates. People are responding is it reacting to the mid date in the of all by converting the fulltime employee of parttime employees this is not a desirable outcome. And the can all agree that we would note people to have the choice of what they can get and when they can get it. We want that to be affordable. Rather than the government mandate. Estate market is better able to provide these services and no doubt. The Health Market is the issue where it is a not the best provider when you have a case in order to get insurance the people who have preexisting conditions if you had a case for their offered Health Insurance on the private market and they can say i dont want to ensure people who are unhealthy those who need it the most cannot get it. That is what is happening with obamacare. In increasing the premium they see an increase in the premium the when they are no longer young and healthy but theyre balancing this to get Good Health Care throughout their life this is the whole economy and work force it is very possible to start of intrapreneur ship. People will say i cannot go out on my own because i cannot afford Health Insurance. Them accusing gannett in the affordable way through obamacare since you can start that business. We dont know how this will play out but i do believe it is the right direction for our economy. But we dont know what will come in we dont have a free market in health care. To almost half of the spending is done by eighth the government we cannot say it is anything that resembles a market. Host lets take look at some tweets. Are baby boomers staying in the work force instead of retiring . That is interesting because one of the things that we talked about is people giving up working in that one exception is seniors they are staying on longer you can understand they have seen their wealth disappear in theyre worried about the future. Idle think it is Holding Back Employment because we want a bigger share because that is what sustains the population would get how seniors working longer with this very interesting phenomenon. But i have done some digging to look hall of the missing workers not in the labor force that would be if the job opportunity was stronger and if you break it down by gender and age there are few were muslim workers the retirement age but there are some there are fewer 55 if the Job Opportunities were stronger. So more people near retirement age are justin the point of their life cycle and they saw the bursting of their housing bubble so there are staying some but the dominant factor is the loss of Job Opportunities. And we do have those better older than 55. Heidi shierholz if from dpi and also veronique de rugy from george mason and university looking at the economy, how much of the of the drag is it now on the economy into the future . It is a part of the deal with the debt ceiling and it is across the board Government Spending. So that is the frustration that is the wrong thing to be doing. The evidence is overwhelming austerity that is deficit reduction during a slump has big negative effects pulling the spending and out of the economy and that will cost jobs so we do see a big drag on the economy we have not seen the full effects yet but i expect to see that more strongly in the next couple of months. I agree it was a very blunt instrument if we are concerned about future debt that is the wrong part of the budget even though everything not to be on the table but the level of the future debt this comes from other way to protect. We were told this guy was going to fall looking but how many actually materialized . When the the thing is particularly interesting to talk about is sequestration but to know how it will play out because it is the ability to do that so we heard it would be devastating for defense contractors like a hundred billion dollars alone and then it was up 10 so there is the way. We agree it isnt the best way to be fiscally responsible but i do think we heard all of that to materialize. I have a couple points to make. I give the administration a f with economics look at the black Unemployment Rate nobody talks about this. Not the congressional black caucus, and not the obama, nobody. Of this program should devote more time to the black Unemployment Rate and it has gone up this year. Then you look at the whole debate of the minimumwage if the black folks can find jobs at 7. 25 per hour with you think will happen . Not only blacks but of lower skilled people at 12 an hour . This is a big focus and the actual Unemployment Rate in chicago is 19 percentage of all this Government Spending will take this economy to a good situation it would have happened by now because we are running up debts somebody will have to pay for in the liberals never talk about who will be around to pay the debt. Host redo see a story in the news that does say 13. 7 percent for black americans in june this year is to say there is a perpetual slowmoving recession. He is absolutely right black unemployment is extremely high. It just shows the black Unemployment Rate is about twice of flight in good times and bad times the rate just remains very high. But with though labor market overall the biggest we could call we could pull with substantial additional stimulus to bring down the an employe in a rate in the the thing i seeing he said is really important it is the minimum wage but research is conclusive now the increase of the minimum wage so he should know there used to be more ambiguity but the research is really clear now that it has increase the wages of the workers. Even in times of high a unemployment because we know it will increase wages at a time when you increase the minimum wage with seven jobs you just to shift the money from the corporate profit balderdash profits into the he of of people who will spend it period that stimulates the economy to stimulate jobs. This is the perfect time obama the talk about it but this is the perfect time to drust minimumwage would help the low wage black worker as well. Host will receive on twitter what we do you think about the number of wage increase . We have had a lot of Government Spending at just under obama. He is a gigantic spender actually obama it ambushed are much more similar but there is a part the has not cut the job losses soda actually stops people from hiring because of their unemployment they have lowskilled. You will not hire them because of the increase but those people that do not have the jobs right now if people are not employed right now but in addition was the cost of labor but for that to help cover probably not but because this is the best way to help the workers a and fear is a proven way of the unemployed rate figure and to better but what you want is you want it to be sustained the government doesnt have many of its note so what has to take it from somewhere else there is a lot of contention from government better heard so low skill a. M. For people talk about the economy and the record of the above is administration there are issues with said George Mason Center also joined by 85 economist at the Economic Policy institute. We have the york on the independent mind. Caller could you please give the top five or six actions the government could do to break down regulations and uncertainty how it would affect labor and how that cause the labor collapse in 2008 . I will listen. Anything from the labor market is a good thing to get rid of all of those stains that hinder. The start of that would be very good thing but the tax code but obama has talked about this. Not just marginal but the tax code is a nightmare a and it is complicated benefiting the higher cost businesses but it is truly efficient lenient to reform the tax code. It has a fundamental reform we need to put an end to produce some. Of not the signature of the Obama Administration but they actually cater to their special friends at the expense of everyone else. Said you need to prevent of these businesses at the expense of everyone else. For all those that companys debt because of their power. Host first lets listen to president obama is comments on tax reform. He was making the economic picture speaking at knox college in illinois on wednesdays. I hear from too many people across the country they feel that retirement is receiving from their grasp getting farther and farther away. They cannot see it. Now today of rising stock market has millions of retirement valances going up some of the losses from the crash have been recovered but we still have the upsidedown system but the folks at the top like me get generous tax incentives to save wall hardworking americans who are struggling get none of those breaks at all. So as we work to reform our tax code we should find new ways to make it easier for workers to put money away and keep from them the fear that they cannot retire. [cheers and applause] and if congress is looking for the bipartisan place to get started did not have to look for look far we talk about Immigration Reform that makes undocumented workers pay their fair share of taxes and net shores of the Social Security system for years. [cheers and applause] host net was wednesday at knox college. Right now we have the tax code it is progressive but it has gotten less so over the last few decades. It does some redistribution but less so than it did. Dick is strong public support taxing the wealthy more have them pay their fair share but those subsidies under obamacare were already implemented. Host we will listen to a caller from north carolina, a democrat. Caller first of all, i would like to say with president bush in the republicans with their Economic Policy in the economy collapsed with their policy but to talk about the republican freemarket that is what crashed the economy. Host then what grade did you give the Obamacare Administration . Caller he has tried everything. Host so he gets the a for ever . Effort. Caller he has a jobs bill that has been in congress and they refuse to act on it since 2011 now talk about the high black and employment if the president said today he would consult with the special program there would be complete outrage so he is doing everything he can to try to help the economy but republicans decided that they would do everything that they could to undermine his presidency. I think to be governing for many years there is no free market they talk a good game but it increased by 53 under president clinton and then it was approximately 5 and then spending has gone down but as for the republicans and that they get in the way back yet obama has managed to pass gigantic bills and there is a lot of bipartisan support for they are pretty much in agreement to continue the same policies as they continue them into this term. But to see that. Host lets hear from a republican from corning i was. Caller does anyone remember or no of the crash of 2008 in the housing double . Double. I am and i won. You are absolutely right it was the bursting of the 7 trillion housing double you are right that housing bubble caused that in now still feeling the effects we will not get back to the held for another five years at least that will likely cause is unemployed in hardship for the american workers. Hopefully the Federal Reserve can know it is there job to look out for the asset bubbles to keep this from happening. Host are you still with us . Caller i lost a 35,000 a when the Balance Sheet shows that zero now the stock market looks good but i will not be too fat. Second we bailed out the 50 million for gm and they still owe the American People 80 million but they spend all that many building plants in china and mexico we will never see that many. It was nancy pelosi and harry reid and the democrats that pushed those people that could not afford a mortgage faith in them and they admitted that. I am so afraid for our country. Host the first tweet the housing bubble created by pushing the American Dream to own a home in the late 90s. The housing bubble was built of the government and private sector marriage but to favor in industry that is the American Dream and that creates a bubble coho that is asking too much of people to monitor but yet no one really listens maybe they also think of the housing and it isnt clear for those in favor housing but also there was so lot of couples bubbles and other industries again is not the government alone but the important player was the governments role in Housing Finance but it is also the private sector the government is taking winners and losers so a lot of disruption for people in the economy. Obamacare talked about housing in his speech on wednesday lets take a listen. The good news over the past four years we hope to overstate in their homes today prices are up and fewer americans see their homes under water. But we are not done yet. That aquino is to encourage Home Ownership not based on unrealistic bubbles but a Solid Foundation with buyers and lenders playing by the same set of rules that a clear and transparent and fair. Already have passed congress to pass a good bipartisan 92 be championed by mid romneys economic adviser. The idea to give every home owner to the idea to refinance weld rates are low so they could save thousands of dollars per year. [applause] that is like a tax cuts for families to refinance. And acting in my own to cut red tape for those that want to get a mortgage but the bank says no. We will work with both parties to turn the page on fannie mae and freddie mac to build the Housing Finance system that is rocksolid for future generations. Host president of on a speaking at knox college we have Heidi Shierholz an economist at the Economic Policy institute. We also have veronique de rugy from George Mason University we now have an independent scholar. Caller good morning. President of thomas spoke of the u. S. Economy of now and in the future. If the government i hope it does not prop up failure but instead you can create 2100 or 2200 justin city with the most modern city environmentally housing in people in business the 2100 and 2200 detroit jet sin city would be a place where the world would come to see and study and teach to help create cities of the future. Host talking about the jury to be a moment of opportunity for the next generation . I dont know of lot of details but she brings up a good point when the we could not do right now is that some of those places that were hard hit in the jury would be one of those. At a time like this very time specific we would not want to do this but if we are really an a slump in private companies are not investing it was never tried the original stimulus package was very much the government not hiring people but this time we could have that program with tho that program with those that are hard hit but for those that have sustained high unemployment. I feat of the government policy there is a lot of money to save the city in the government and they think that but unfortunately the way you decide to invest the way this to me this money is spent when you look at you try to achieve the goals that the obama is administration said wishes to hire people with the way it works is you hire people from the unemployment line this will not happen within the other difficulty that people on the ground may not respond the way they hope they will. It is of a project of detroit in the government gives money to the states hoping that it will hire to initially use the money actually filled the budget gap i think too much faith that we put in the ability of the government and even when there is a problem to actually deliver a and i think detroit is a good example but unfortunately Government Intervention of lot better to have to be paid for by someone. Host in the and it is our next caller. He is a democrat. Caller i would like to agree with the 01 guest. Cronyism is a big problem in washington d. C. And people need to realize we need to get the old people out and the new politicians a and i also agree with you the woman that detroit would be a good place to start a new deal and there really think that is what we need the politicians to have the guts to go forward to implement a new deal. Host take you for your input. Now we have a republican callers. Caller what about the 17 trillion debt . What effect does that have on our Economy Today . It if you compare liberalism against conservative is and you can you can go ohio to illinois. Ohio is coming at of its recession recession but illinois is like california practically in bankruptcy. We will have to get back to the old responsibility you have to get out and work. I am glad you asked that question did deficit increased a lot of the recession not because of spending but it naturally increases in a crisis because people live being there jobs but anything related to unemployment goes up in not just of upturn or the downturn. But that actually helps looking at the private sector Economic Activity goes way down people are spending but that means we will not get out of this and that is exactly the time with the government coming in to generate temporarily is what we need. It is interesting and sorts of faults obama for not letting the public understand. He was out there in 2010 with businesses in the American People are tightening their belts the devilish to tighten their belts but actually that is completely wrong at a time when the American People to tighten their belts, when people are not spending spending, business is not investing, exactly that is when the government needs to step been to pull us out. This is a time for the detriment to spend or pullback from the it Economic Policy institute we have Heidi Shierholz and veronique de rugy is from George Mason University. Dat and the government should be helping covet we are out of the recession for about four years in the economy is growing and according to of this news in good times, the problem is all the people who advocate more spending are not calling for that there for rigged to spend less. This is true but there cup is designed but then when they start to roll back they go way back to spending like crazy at the federal level it only goes one way. It is up and up. That time they spent more into more and more. That governments should be spending money in the short term but we have a and then we talk about the above is Administration Economic record we have an independent scholar from maryland. Caller thank you for the opportunity to speak. Rate fell for his recovery he should put those the fold on top or any other issues but why would the economic recovery plan. In some will say it is already too late but to look at Energy Independence and made in america principal we should all Work Together to help the economy around and then be looking at a very long recovery. But to me was so small women known to. Guess i will submit to work with him and to we would all be standing at the g. O. P. But i dont want to do that for me or my children. Host first lets listen to obama talking about his perspective on manufacturing and green jobs this was his speech yesterday from jacksonville, florida. We have to bring more jobs back to america. We have to keep creating good jobs in manufacturing we have to create good jobs with the solar energy and those we had to collect more jobs which is right here part of your future. Host the president is talking about manufacturing. What you want to see happen . One of the biggest thing is i will get a little wonky but i can make it simple