Sheila P. Burke, RN, MPA, FAAN Harvard University

1. National Forum of State Nursing Workforce CentersDenver, Colorado June 12, 2015Federal and State Policy Perspectives: Focusing and Targeting Collaborations to Achieve Impact Sheila P. Burke, RN, MPA, FAAN Harvard University Baker, Donelson, Bearman, Caldwell & Berkowitz, PC

2. Unique Features of U.S. Health Policy Making • Very frequent elections • Weak government executive branch at all levels • Strong difference in values between political parties • Strong role for major private interest groups • Strong role for public opinion

3. Congress and Health • Deeply divided electorate on the role of government • Deep partisan differences on government health care programs • Congress plays a major role in development of health policy • Authority spread across several committees • Involvement includes regulatory, programmatic, financing, and oversight

4. Examples of Congressional Legislation in Health Policy • Enactment of Medicare and Medicaid (1965) • Employee Retirement Income Security Act (1974) • Americans with Disabilities Act (1990) • Family Medical Leave Act (1993) • Temporary Assistance for Needy Families (1996) • Health Insurance Portability Accountability Act (1996) • State Children’s Health Insurance Program (1997) • Medicare Modernization Act (2003) • Affordable Care Act (2010)

5. Mary Eliza Mahoney New England Hospital for Women and Children’s Nursing School, 1879

6. Triple Aim • Improving the patient and provider experience of care • Improving the health of populations • Reducing per capita cost of health care

7. 17 Major Components of Federal Expenditures% of GDP 2011-2051 % of GDP 14% Healthcare 12% 10% 8% Social Security 6% Discretionary Spending 4% Other Mandatory Spending 2% 0% 2011 2021 2031 2041 2051 Source: Congressional Budget Office. WWW.BIPARTISANPOLICY.ORG

8. Federal Spending Projected for 2024 11 Medicaid (10%) Social Security (26%) Medicare (15%) Other Health Programs (3%) Other Mandatory Spending (7%) Domestic Discretionary (11%) Agriculture (0.3%) NetInterest (15%) Defense (12%) Health Programs” includes: Health insurance subsidies, exchanges, and related spending; Department of Defense Medicare-Eligible Retiree Health Care Fund (including TRICARE for Life); Children’s Health Insurance Program, and other programs. Source: The Congressional Budget Office. The Budget and Economic Outlook: Fiscal Years 2014 to 2024, February 2014.

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

10. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008. Infant Mortality Rates, 2004 Infant deaths per 1,000 live births National Average and State Distribution International Comparison, 2004 Data: National and state—National Vital Statistics System, Linked Birth and Infant Death Data (AHRQ 2003, 2004, 2005, 2006, 2007a); international comparison—OECD Health Data 2007, Version 10/2007.

11. Projected Age Distribution

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

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

14. Examples of Congressional Legislation in Health Policy • Harvard presentation

15. Believe Responsibility of the Federal Government to Make Sure All Americans Have Health Care % saying yes, is federal government’s responsibility Democrat 71% Republican 20% Gallup poll, November 2011

16. Concern about Government Involvement in Health Care, by Party % saying they are concerned about the government becoming too involved in health care Republican 88% Democrat 37% Pew poll, June 2012

17. A New Era in Health & Health Care

18. Florence Nightingale

19. Civil War Nurses

20. Spectrum of provider payment: reform trajectory moving towards global payment Current payment for units of service Add pay for performance Subtract payment for preventable complications Mixed payment (patient-centered medical home) Episode-based (bundled) payment Global payment

21. Research

22. Improving Quality and Reducing Costs – Center for Medicare and Medicaid Innovation (CMMI) • Accountable care organizations (ACOs) • Chronic disease management • Patient-centered medical homes • Health Information Technology (HIT) • Quality reporting • Duals demonstrations

23. 2015 Policy Discussion: Key Issues Bubbling Up Workforce shortage Employer mandate Funding of research Coverage of those in states not expanding Medicaid Coverage of undocumented immigrants Delivery system reform Narrow networks Privacy Individual mandate Big Data Affordability of premiums and cost-sharing Court challenge to subsidies in federal marketplaces Churn Chronic Illness

24. Next Steps • Start at Home • Find a Mentor • Learn by Doing • Ask the Tough Question • Be Informed • Volunteer

25. Rules • Bring the evidence to the table • In presenting data, be short and to the point • Narratives that put a human face on an issue have an enormous impact • Timing / Windows of Opportunity • The importance of building bridges and finding partners/advocates • Don’t burn bridges • Know what you Know and Don’t Know • Know your audience!

26. Conclusion