Health Resources and Services Administration
Office of Rural Health Policy
June 11-13, 2006
The 53rd meeting of the National Advisory Committee on Rural Health and Human Services was held on June 11-13, 2006 in Camden, Maine.
The meeting was convened at 1:30 on Sunday afternoon. Mr. Tom Morris, Office of Rural Health Policy (ORHP), announced that Governor David Beasley, Chairman of the Committee, had been delayed. He extended thanks to Dr. Lenard Kaye for hosting the meeting and making the arrangements. He also announced that this would be the final meeting for one member of the ORHP staff and introduced several new staff members.
The members present were: Susan Birch, RN, MBA; Evan Dillard, FACHE; Bessie Freeman-Watson; Julia Hayes; Lenard Kaye, D.S.W.; Michael Meit, M.P.H.; Arlene Jackson Montgomery, Ph.D.; Larry Keith Otis; Patti J. Patterson, M.D.; Thomas C. Ricketts, Ph.D.; Senator Raymond Rawson, D.D.S.; Sister Janice Otis; and Mr. Tim Size. Members unable to attend were: Ron Nelson, P.A.; Ms. Heather Reed; Mr. Joseph Gallegos; Michael Enright, Ph.D.; and Joellen Edwards, Ph.D. Present from the Office of Rural Health Policy were: Tom Morris, MPA, Phuong Luu; Emily Cook, M.S.P.H.; Thomas Pack; Caroline Cochran, M.P.A.; Erica Molliver; and Andrea Halverson.
Dr. Barringer discussed the four political-economic eras in Maine history beginning with early settlement in the 1600s through the modern post-industrial era. He described how the economic life of Maine has evolved in the areas of agriculture, fishing, manufacturing and other economic sectors. He also reviewed the dramatic changes that have taken place in Maine over the past five decades and the State's current transition to a post-industrial urban economy. Maine has become a state where the vast majority of citizens live in cities and cities are where the majority of citizens are employed. At the same time, more people are moving further outside urban areas. Dr. Barringer discussed this transition from rural to "suburb" and its effects on land use and natural resources. Dr. Barringer also talked about the persistence of poverty in Maine and how poverty has moved from coastal areas toward inland areas of the state. He said that Maine's greatest challenges for the future are to strengthen its natural resource-based industries, increase research and development in such areas as aquaculture and biotechnology, and increase investments in adult learning, especially the Maine Community College System. Other challenges include the creation of affordable workforce housing and the development of entrepreneurial efforts based on tourism, outdoor adventure, boat building, and other assets in the state. Dr. Barringer concluded his presentation with a discussion of economic strategies that have not worked well in the state and those that have.
Ms. Johnson spoke about the changing face of rural addiction in Maine. Currently, drug abusers are more likely to be female than in the past; more likely to be young than in the past; more likely to be in the ages of 18-25; and more likely to be using drugs other than alcohol. She reviewed current data on treatment admissions for drug abuse that demonstrate these trends. Alcohol is still the highest cause of drug abuse for men, but the use of injected drugs is growing. Also, there has been a huge increase of alcohol abuse treatment admissions for women age 55-85. Increasing numbers of both men and women are seeking treatment for methamphetamine abuse. Ms. Johnson stressed the importance of rural primary care physicians in treating addicts. She said that they are already treating addicts, but often don't know it. Physicians need to be included at all levels of treatment and prevention, including screening, brief interventions, follow-up, and medication management. She placed special emphasis on the need to follow those who have received treatment and to keep them in treatment programs.
Dr. Harley described the data that will soon be available from a national survey of drug abuse. It is not yet ready for publication. When the data does becomes available, it will provide up-dated information on the extent of drug abuse in rural areas of the country, as well as current trends in drug abuse among various age groups and ethnic populations in rural America. The data will be from a household survey conducted by the Substance Abuse and Mental Health Services Administration.
Dr. Gilson presented his work at the University of Maine to "examine the fit between environment and prevention intervention" in drug abuse. The study is developing knowledge to support drug abuse prevention planning and implementation, with a focus on underserved communities. The study is relying on geographic coding and statistical analyses to answer four questions: (1) Where is the current prevention infrastructure in place; (2) What is the population density in diverse locations of the state; (3) What are the patterns and severity of illegal drug consumption; and (4) What are the relationships between prevention infrastructure, population density, and patterns of consumption. Dr. Gilson showed the Committee several examples of how maps and statistical analyses produced by the study can be used in developing drug abuse prevention strategies. On the basis of maps and statistical studies, four communities will be chosen for in-depth investigation of drug abuse patterns and prevention resources.
Mr. Size asked about drug abuse prevention activities in the state. The speakers responded by describing several different approaches and agreed that the place to start is with alcohol abuse since it often leads to the use of other drugs. There is a need to identify children at-risk and increase educational efforts for both children and parents.
Senator Rawson mentioned that some states were using funds from the tobacco settlements to support drug abuse prevention programs. He also said that states looking to legalize the use of marijuana are sending the wrong message. The speakers agreed that publicity in this area might have an effect on marijuana consumption.
Ms. Totten presented the demographics of the Medicare population in Broome County, a rural area in Upstate N.Y. In Broome County there are 39,886 Medicare beneficiaries and 97% of them are enrolled in the traditional Medicare program. During the late 1990s there was an exit of Medicare HMOs in the County that left behind a legacy of mistrust for Medicare managed care. Medicare Advantage was introduced in 2004, but there has been very little market penetration to date. As of December 2005, there was 2.76% Medicare Advantage enrollment in the County. Blue Cross and American Progressive have had the most success. Ms Totten presented data showing that enrollment rates were higher in other rural areas of the State. She said that the reasons for low market penetration are: Plans are misunderstood by beneficiaries who think they require leaving Medicare; (2) Premiums are so much lower than Medigap, that some are led to believe that it must be "too good to be true;" (3) The older population is not used to managed care and remembers the HMO pullout of the late 1990s. (4) Fear of out-of-pocket expenses when they are accustomed to very few such expenses under Medigap; (5) Lack of maximum out-of-pocket expense that would minimize risk and increase comfort level; (6) Concerns over restrictions on use of providers and premium fluctuations. Among the primary motivators for moving to Medicare Advantage are the rising costs of Medigap insurance and the coupling of the new Medicare prescription drug coverage with Medicare Advantage plans. Some of the reasons for enrollment differences among rural counties are the presence of well-established and trusted plans (no pullout in the 90s) and Social Services Departments that regularly place people in Medicare Managed Care plans.
Mr. Size commented that in recent months the Medicare Part D program has dominated the landscape, diverting attention from the Medicare Advantage program.
Senator Rawson said that it is difficult to reach a real person at the Centers for Medicare and Medicaid for answers to questions about Medicare Advantage. Ms. Totten replied that personalized assistance is a big factor in keeping seniors interested and in helping them to be comfortable with the program. The lack of materials that allow comparisons between plans is also a major problem.
Ms. Drugge reviewed the relevant demographics in Maine, highlighting that Maine ranks 38th among the states in total population with a population density of only 40 people per square mile. There are 16 counties in the State, with 10 counties that qualify as frontier. The population is concentrated in the three major cities of Portland, Bangor, and Lewiston. Ninety-seven percent of the population is White. In the year 2000 there were 70,726 children under age 5, a decrease of about 15,000 since 1990. Almost 30% of children age 5 and younger live in poverty. Annual wages rank last in New England and 34th in the United States. There are 12 head start grantees in Maine administering 208 programs, including 27 Early Head Start programs. In FY 2003 there were 3559 preschool children served by Head Start and 496 children ages 0-3. Head Start collaborates with public school pre-kindergarten programs at various sites and using several different models of collaboration. Head Start offers childcare services for working parents and receives funding to support these services. The State has developed early childhood learning guidelines used by Head Start and public school programs. The State is using tobacco settlement funds for extended day and extended year services. The rural challenges for Head Start include high transportation costs, especially the recent rule change mandating school bus transportation. Low population density makes it difficult to offer center-based programs. On the policy side, the increased income requirement to no more than 140% of the federal poverty level has eliminated eligibility for children who need the program. Also, there is a need to coordinate policies at the federal level to support purchase of vehicles that meet Head Start safety requirements.
Ms. Hayes asked about children from families that do not meet the federal poverty guidelines. The speaker responded that many of these families are unable to find public pre-kindergarten programs for their children.
Governor Beasley asked for public comments. There were no comments and the meeting was adjourned until Monday morning.
Governor Beasley convened the meeting at 8:30 p.m. and provided a brief overview of the site visits that would take place during the day.
The Substance Abuse Subcommittee departed for a site visit at the Bucksport Community Health Advisory Committee in Bucksport, ME.
The Head Start Subcommittee departed for a site visit at Head Start for Washington and Hancock Counties in Ellsworth, ME.
The Medicare Advantage Subcommittee remained on site for meetings with officials representing insurance companies that offer Medicare Advantage plans.
At 2:00 p.m. the Subcommittees returned to the meeting facility for separate meetings on their respective chapters to be included in the Committee's annual report to the Secretary for 2006.
The Subcommittee meetings were adjourned at 5:00 p.m.
Chairman Beasley convened the meeting at 9:00 a.m. He began the meeting by recognizing Senator Rawson's service on the Committee. This was the Senator's final meeting.
Mr. Morris reminded the Committee that the next meeting will be held on September 28-30 in North Dakota. He also recognized Ms. Phuong Luu for her work with the Committee. Ms. Luu will be leaving the Office of Rural Health Policy in July to attend medical school.
The Chairman asked each of the Subcommittees to report on their work related to the annual report.
Medicare Advantage Subcommittee: Mr. Size briefly described the program and reported that there are no current data on enrollment. The Subcommittee is focusing its attention on private-fee-for-service plans and Regional PPOs since these plans are more likely to be found in rural areas. He said that past enrollment in Medicare managed care plans is not a good predictor for the future and that Medicare Advantage plans can work well in rural areas. The senior market is a growth area in Maine and plans are bullish on enrollment. Private-fee-for-service plans have the biggest growth in rural areas. The Subcommittee is working on recommendations related to technical assistance for rural seniors, coverage of prevention services, rural access standards, the need for timely enrollment data from the Department, and requests for research where more information is needed.
Substance Abuse Subcommittee: Dr Patterson described the site visit that took place on Monday and the constant battle for funds that is waged by substance abuse treatment and prevention programs. She mentioned the importance of school-based education and prevention programs and the need to change the culture of drug abuse. The Subcommittee is looking at creative rural models for treatment and prevention. Specific recommendations are under consideration.
Head Start Subcommittee: Ms. Hayes described the site visit of the previous day and reported that recommendations are likely in the areas of federal funding guidelines, program collaboration, financial eligibility, and professional development of Head Start grantee staffs.
Mr. Morris asked for comments on the letter to the Secretary that will be sent following the meeting. There were no comments. The letter will be drafted by staff and submitted to the Committee for approval.
There were no public comments and the meeting was adjourned.