2007 Arizona Rural Policy Forum Final Report Challenges, Solutions & Opportunities Affordable Housing Workforce Training Recruitment & Retention of Health Care Professionals Prepared by The Arizona Rural Policy Institute A unit of the Center for Business Outreach Michael Lainoff & Jeff Peterson, Authors J. T. Mackey, Graduate Assistant This report was prepared by the Arizona Rural Policy Institute, Northern Arizona University, partially funded under award #07-66-05876 from the Economic Development Administration, U.S. Department of Commerce. The statements, findings, conclusions, and recommendations are those of the authors and do not necessarily reflect Development Administration or the U.S. Department of Commerce. the views of the Economic Acknowledgements The 2007 Arizona Rural Policy Forum was made possible by the contributions and efforts of the following sponsors: Table of Contents Executive Summary .................................................................... 1 Affordable Housing ..................................................................... 4 Workforce Training ................................................................... 10 Recruitment & Retention of Health Care Professionals ............ 16 Conclusion ................................................................................. 24 Appendix ............................................................................. 25-33 Arizona Rural Development Council .................................... 25 Panel Chairs & Recorders .................................................... 28 2007 Forum Participants ...................................................... 29 Executive Summary The first annual Arizona Rural Policy Forum convened on July 12 & 13, 2007 at The W. A. Franke College of Business, Northern Arizona University (NAU). 149 community leaders (including numerous city/county/state elected officials) from all regions of rural Arizona participated in an intensive twenty-four hour dialogue. The agenda focused on three major topics: Affordable Housing, Workforce Training, and Recruitment & Retention of Health Care Professionals. The Arizona Rural Development Council (AZRDC) convened the Forum, with the assistance of NAU’s Center for Business Outreach. Other sponsors included Arizona Public Service Company, Arizona Community Foundation, Blue Cross Blue Shield of Arizona, Freeport-McMoRan Copper & Gold, Inc., and the Arizona Lottery. Prior to the Forum, participants received a thirty page background report, “Challenges, Solutions & Opportunities,” prepared by the Arizona Rural Policy Institute (ARPI). The report presented a common framework for each topic, as well as a summary of best practices from rural America that provide solutions for these critical issues. The Forum was launched on Thursday afternoon with a Legislative Panel Discussion on Rural Policy. Representative Lucy Mason (Prescott) served as the moderator for the panel that included Representative Ann Kirkpatrick (Flagstaff), Senator Tom O’Halleran (Sedona) and Representative Bill Konopnicki (Safford). This session was followed by a brief overview of topics by three presenters: Dr. Sheila Harris, Director, Arizona Department of Housing; Mr. Marty Laurel, Vice President for Community Relations, Blue Cross Blue Shield of Arizona; and Mr. Michael Lainoff, Director, ARPI. The Forum participants were assigned to six “break-out” discussion groups, where they engaged in facilitated dialogues with assigned content experts, ninety minutes per topic. Research analysts from the Arizona Legislature were also assigned to each group as recorders; they documented their groups’ discussions, and provided the ARPI with compilations of the sessions’ findings. The sessions addressed the following questions: • Which best practices will help move the issue forward? • What resources do we need to implement the strategies? • Who else needs to be involved? Arizona Rural Policy Forum 2007 – Final Report 1 Although discussions were engaging and productive, the groups’ levels of detail in responding to all three questions varied significantly (from issue to issue/group to group). As noted in the following summaries, groups identified and endorsed a sufficient number of best practices within all three topics. However, in many cases, the proposed solutions did not include specific follow-up recommendations, e.g., which entities should take the lead for advocacy and implementation. Consequently, the Forum’s principal sponsor (AZRDC) will be identifying priorities for advocacy and implementation. In turn, the Council will be contacting and recruiting appropriate individuals/organizations for specific tasks. Upon completion of each session, recorders’ notes were perused to identify salient points of consensus throughout the six groups. Accordingly, six general recommendations were identified for each topic. Participants were provided with the following list at the Forum’s final session: Affordable Housing • Improve/increase use of public lands for affordable housing; • Public/private partnerships for incentives and funding; • Legislative changes to increase available tools for local governments; • Comprehensive homebuyer education program addressing rural issues and resources; • Innovative solutions to reduce construction costs; • Employer Assisted Housing (EAH) including sweat equity and shared equity opportunities. Workforce Training • Public/private partnerships throughout P-20 (Pre-kindergarten through “Grade 20,” or doctoral degree); • Retention and return of youth/trained workers to rural communities; • Increase access to college/university level education for rural areas; • Comprehensive data driven solutions via applied research; • Local needs drive regional plans for collaborative solutions; • Legislature to re-examine funding formulae throughout P-20. Arizona Rural Policy Forum 2007 – Final Report 2 Recruiting & Retaining Health Care Professionals • Improve the health professions pipeline; • Enhance training opportunities (including continuing education for incumbent; practitioners and specialized/technical training); • Expand current telemedicine networks for diagnostics treatment and training; • Comprehensive public/private partnerships for facilities, equipment and training; • Increase Student Residencies in Rural Communities; • Encourage State Legislature to pursue Tort Reform for malpractice. The following summaries encompass the six groups’ deliberations and findings on the key issues. The authors of this Final Report have highlighted the major points of consensus within each discussion. Whenever possible, the divergent perspectives and opinions expressed during the sessions were included. Please note that the AZRDC and other entities enlisted for further analysis and implementation will fully consider the entire volume (nearly fifty pages) of recorders’ notes. Arizona Rural Policy Forum 2007 – Final Report 3 Challenges, Solutions & Opportunities — Affordable Housing in Rural Arizona The six panels deliberated the challenges and potential solutions for rural Arizona’s affordable housing crisis. At the heart of the problem is the fact that Arizona is currently leading the nation in median home price increases, which places home ownership beyond the reach of a large portion of its workforce. Panels’ recommendations included: • Improve/increase use of public lands for affordable housing; • Public/private partnerships for incentives and funding; • Legislative changes to increase available tools for local governments; • Comprehensive homebuyer education program addressing rural issues and resources; • Innovative solutions to reduce construction costs; • Employer Assisted Housing (EAH) including sweat equity and shared equity opportunities. Public Land Projects One of the major issues addressed was how to acquire land for use in affordable housing projects. With over 60% of Arizona unavailable for development, land has become scarce. Recurring suggestions purported acquisition of land from a number of sources, including banks, developers, and state government. Every group suggested the use of state lands for the creation of low-income housing. Land swaps with private entities and use of state trust land have a benefit of keeping costs under control. A downside is the difficulty in developing these lands due to backlash that occurs when public land is used for private interests. Another approach is the redesign of existing structures. An excellent example is a project in Ajo that transformed the historic Curley School, an abandoned seven-acre school, into thirty affordable artists’ apartments. Proposed over four years ago, these apartments are now over 80% leased. While this project has focused on bringing artists into Ajo, similar projects could be used to provide housing for a rural area’s workforce. Partnerships and Solutions for Incentives and Funding Several proposed solutions would significantly increase funding for affordable housing initiatives. One group suggested setting aside a percentage of interest from escrow accounts from the re-sale of homes or state land trusts, and directing it to housing or revolving trust funds. Housing trust funds have already been implemented in some counties. An excellent example that could be replicated is Pima Arizona Rural Policy Forum 2007 – Final Report 4 County’s Affordable Housing Trust Fund, which assists Pima County’s low income residents with housing purchases. Revenue for such funds can be attained by following Pima’s example of using both general obligation bonds and a “roof tax.” A roof tax collects a fee from the resale of homes in a county, and directs it to a trust fund. It was also suggested that Arizona should reorganize the distribution of private activity bonds. If any bond revenues allocated for student loans and manufacturing are left over, they should be allocated to single-family housing projects. General consensus suggested that funding for affordable housing initiatives can result from partnerships between public and private interests. It was assumed that the private sector would be able to meet certain needs that the public sector cannot. Additionally, work by private companies is essential in creating a sufficient amount of affordable housing. Nearly all groups discussed tax breaks for developers as an incentive to encourage green building, which can reduce ongoing utilities and maintenance costs for homeowners. Density bonuses can also play a large role in affordable housing. They allow developers to build at a higher density despite local zoning requirements. A portion of units sold must be affordable. Lower revenues from affordable housing can be offset by an increase in the number of units sold. Private sector investment pools were also suggested. Among their various applications, they can provide down-payment assistance funds, which can be repaid as homes are sold. In regard to tribal communities, several suggestions emerged to help improve deplorable circumstances. While there are numerous/chronic problems with such issues as difficulty in obtaining financing, structuring an affordable mortgage repayment system, and the general lack of Federal funds for housing, the primary issue is the shortage of available/buildable land specifically for home-site leasing. One group referenced the establishment of an independent, self-governing housing institute (currently under consideration by the Navajo Nation and other tribes) which could help solve these problems and offer significant improvements. By establishing its own unique eligibility criteria, awarding grants to its neediest members and acquiring an adequate monetary pool for distributing loans to its members, Arizona Rural Policy Forum 2007 – Final Report 5 the housing institute could effectively confront the housing challenges that impact Indian Country. Additional functions that the housing institute could perform include: • Develop and implement a financial training program that would better prepare Native American home buyers; • Work collaboratively with the Indigenous Community Enterprise (ICE), Arizona Department of Housing (ADOH) and other entities to enhance new home construction projects; • Restructure mortgage payments so they do not span 40 to 50 years. Finally, a housing institute could help secure land specifically for immediate and timely home construction. Current policies and practices take six months to three years to secure home-site leases. Groups identified solutions that can result from collaborative efforts of community leaders (including elected officials), developers, and established public-private partnerships. These include a property tax for second homeowners, reduced development fees for affordable housing, and impact fees for a variety of services including law enforcement, fire protection, and libraries. Community funds, receiving the proceeds from fees and other sources of revenue, can be used to fund affordable housing. Also of importance is the constant search for appropriate market areas for the assignment of new fees and taxes, along with continued awareness of opportunities and facilities available in individual communities. Groups identified the following resources to help accomplish these proposed solutions: HOUSING RESOURCES Arizona Department of Housing Federal programs and grants IDA's (industrial development agencies) Developers The Housing Institute Latent government assets (vehicles, land) Stardust Center for Affordable Homes and the Family at ASU Department Housing Community Foundation Community Reinvestment Act Tax Liens and Auctions Arizona Housing Commission Community Input Federal, State, Local and Tribal Legislators Arizona Rural Policy Forum 2007 – Final Report 6 Legislative Changes During the discussions, one of the main points that emerged was a need to modify legislation that currently restricts counties, cities and towns from enacting solutions to combat the affordable housing problem. Various constraints are placed on community leaders by local, tribal, state and federal governments. Arizona law prohibits the exemption of certain types of housing from impact fees. Changing this would allow governments to offer reduced or waived fees as incentives. Also, certain propositions, such as Proposition 207, limit the government’s use of the eminent domain that could be beneficial in acquiring land for affordable housing projects. Current law also prohibits inclusionary zoning, which allows municipal governments to adopt regulations requiring developers to provide certain amounts of housing at reduced rates. Legislation would be required in order for this type of zoning to be a tool for affordable housing development. Education Programs Potential homeowners can benefit immensely from comprehensive homebuyer education programs that address rural issues and resources. This includes understanding the overall home buying process and knowing what programs exist to facilitate this process. Participants suggested the creation of a public information system that would educate citizens on obstacles and paths to affordable housing. Special attention should be paid to informing residents in unincorporated areas, as they are often overlooked by municipal outreach efforts. Additional education of local businesses on realities of affordable housing shortages and viable solutions would also be beneficial. When employers realize the advantages they receive by employing homeowners, they may be more likely to become actively engaged in the issue. Moreover, several groups stressed that employers should be encouraged to offer homebuyer education programs within the workplace. It was suggested that any such program take an approach similar to a mass-advertising campaign to ensure broad awareness and recognition. Innovative Solutions to Reduce Construction Costs All groups agreed that housing could be made more affordable by reducing costs of production. New technologies, new types of housing, cost-minimizing approaches, and reduction of zoning and regulatory costs were suggested. Cost-minimizing technologies and methods are introduced through market innovation. For these approaches to be helpful builders must be continuously aware of change in the industry. Using Arizona Rural Policy Forum 2007 – Final Report 7 innovative and locally-available building materials is especially helpful. Examples in rural Arizona include locally manufactured materials such as Flex-Crete, oriented strand board, and other forest products. Flex-Crete is a building material similar to concrete. It is produced in Page at a plant owned by the Navajo Nation. Flex-Crete is five times lighter than concrete, and as a building material it provides for more efficient heating and cooling of houses. Oriented strand board is used widely in home construction, and can be produced using the by-products of forest thinning operations. A proposed production facility may operate in Winslow within the next few years. Additional sources for building materials include the White Mountain Stewardship Project, which will utilize the abundant supply of small-diameter timber. Because these products are produced locally, low transportation costs will increase their affordability. In addition to new methods of traditional building, lower-cost housing can also be encouraged. Manufactured homes are generally built at a fraction of the cost of traditional structures, and provide similar interior dimensions. High-density housing projects can also be encouraged, maximizing the number of dwelling units per acre. Such practices significantly reduce infrastructure costs. Governments can also reduce costs by reducing fees and taxes. Zoning laws and impact fees could be waived or reduced. As mentioned above, the ability to waive such charges will often require legislative action. Employer-Assisted Housing Groups determined that a number of existing best practices should serve as models for employerassisted housing projects. Here, too, examples exist, among both private and public employers. Tyson Foods, a major employer in the South and Midwest, has an excellent program that coordinates homebuyer education and assistance for its employees. A program in Santa Fe, Teacherwise, provides an example of a similar program for teachers. Tyson Foods’ Workforce Home Benefit program is one of the largest employer-driven, employerassisted housing programs in the country. This program is a coordinated partnership between the Tyson Credit Union, a financial counseling service called Balance, the National Credit Union Foundation, and Freddie Mac. Employees that have been with the company for two years and meet minimum income requirements are eligible to receive homeownership counseling and flexible down payment and closing cost assistance. The program has the potential to reach 6,000-7,000 workers. Arizona Rural Policy Forum 2007 – Final Report 8 The Teacherwise Program in Santa Fe has helped 22 teachers purchase homes in the year and a half since its inception. Like the Tyson Foods program, Teacherwise provides down payment and closing cost assistance, as well as homeownership education. This program also partners with the New Mexico Mortgage Finance Authority to offer low-interest mortgages. Programs that include “sweat-equity” have also been popular, and were endorsed during discussions. These generally involve purchase assistance from the employers, matched by an employee’s efforts to restore or repair the property. By personally improving the property value, an employee creates equity in their property. For all of the above solutions to be implemented, communication needs to be improved so an entire community can take part in current programs that are available. Community input is also needed, as is involvement from the Governor, Legislators, faith-based organizations, tribal governments, and rural policy institutes. Private sector entities, including lenders, developers and builders should be engaged in discussions. All groups concurred: with the unprecedented growth of Arizona’s economy and population, affordable housing must become available in every community. All of the appropriate public and private sector entities that can impact these proposed solutions must become fully committed to make them happen. Arizona Rural Policy Forum 2007 – Final Report 9 Challenges, Solutions & Opportunities — Workforce Training in Rural Arizona The challenges and potential solutions associated with workforce training in rural Arizona engendered considerable discourse within the six break-out groups. The six most salient items were: • Public/private partnerships throughout P-20; • Retention and return of youth/trained workers to rural communities; • Increase access to college/university level education for rural areas; • Comprehensive data driven solutions via applied research; • Local needs drive regional plans for collaborative solutions; • Legislature to re-examine funding formulae throughout P-20. Public/private partnerships throughout P-20 • Create statewide Rural County Workforce Council (partnership with counties/ employers) • Expand/replicate currently successful initiatives • Establish collaborative funding pools Rural Arizona’s private sector is responsible for creating and sustaining 90% of the jobs; most training providers (and available resources) are within the public sector. Thus, effective public/private partnerships are critical for successful workforce training initiatives. A statewide “Rural County Workforce Council” could advocate workforce issues for rural counties. The Council could also administer a job “repository” to provide information and assist placement/recruitment efforts. In rural Arizona, some areas have worker surpluses and some have shortfalls, often on a seasonal basis. The County Supervisors Association of Arizona could facilitate the creation of this Council; the “repository” function may be a good fit for the Arizona Workforce Connection’s (Arizona Department of Commerce) “Virtual One-Stop:” https://www.arizonavirtualonestop.com/ Nearly all groups acknowledged the success of current training programs in rural Arizona that benefit from effective public/private collaborations. For example, the power plant training program in Navajo County was inspired by local power plants losing employees through retirement. The solution, a Arizona Rural Policy Forum 2007 – Final Report 10 training program for high school and community college students, resulted from a partnership between APS, SRP, Northern Arizona Vocational Institute of Technology (NAVIT), and Northland Pioneer College (NPC). Ultimately, students are hired at the power plants, at premium wages, upon graduation. Another project, the Occupational Training Center, is a partnership between Freeport-McMoran and Eastern Arizona College/Thatcher. Training activities focus on areas of job shortages (Diesel Mechanics, Industrial Plant Technician, plus Electrical and Instrumentation Technician). FreeportMcMoran is ready to work with other community colleges to expand this program; Forum participants suggested that other employers and colleges also adopt this model. One group suggested expanding an urban program, Partners Advancing Student Success (PASS), where APS and Motorola partnered to develop a professional development opportunity for K-12 teachers. This program brings education and business together to share ideas about how best to incorporate Arizona’s Academic Workplace Skills Standards into classrooms. The groups also suggested public/private collaboration to create funding pools for training initiatives. These resources could fulfill a range of currently unmet needs (especially in light of Arizona’s underfunded K-12 and community college systems), including seed money for program development. Such programs would focus on youth (i.e., internships, career/technical education, skills centers). One group clearly articulated this synergy: “Bridging the gap between youth and job opportunities requires quality, integrated, articulated (between business and education) solutions.” Retention and return of youth/trained workers to rural communities • Inform students early about local jobs and careers • Develop summer internships to generate interest in local jobs • Expand college/university services to non-served communities—keep the students at home • Create incentives to draw trained workers back to rural communities Problems associated with the exodus of young people and locally trained employees resonated throughout the groups. Proposed solutions consisted primarily of local, grass-roots tactics. Quite simply, one group suggested that young, non-professional speakers talk to students about local jobs and training opportunities, recognizing that “youth identify with youth.” A similar idea entailed Arizona Rural Policy Forum 2007 – Final Report 11 introducing children to different types of local employment, so they have a realistic sense of opportunities. Once “introduced,” students could participate in summer internships to further generate interest in local jobs. One group cited tangible applications of these concepts, acknowledging that APS, SRP and other employers reach out to high school juniors and seniors with the promise of jobs after graduation. Groups noted a net decrease in rural communities in the 18-24 year old population, exacerbated by a tendency for students to leave their communities for college and never return. Someone suggested that Arizona’s Legislature should consider four-year community colleges; another group asserted that fouryear community colleges are a “fall back” position, and that universities should partner with community colleges to “keep young people local.” Although these perspectives differed, they were directed toward the same outcome: expansion of postsecondary education to non-served communities and keeping the students in their home communities. As one group articulated, “While it is natural for young people to want to experience the world, it is important to develop ways to encourage young people to come back. Give people options to stay in their community; this includes flexible/ creative schedules. Include young people in the design and building of communities.” All groups perceived a need to develop incentives to draw workers back to rural communities. Viable solutions emerging from the discussions included inviting (community college and high school) alumni and former students back to town and contributing their efforts to the local workforce. Additionally, one group cited the potential for Hometown Competitiveness to retain youth in their communities. For example, in Douglas, Hometown Competitiveness, in partnership with the Arizona Workforce Connection focuses on youth entrepreneurship. The program works with children in middle school on up, and gets them to college campuses. The participating youth team up with local business managers, and obtain skills certificates." Increase access to college/university level education for rural areas • Community colleges in all counties • Improve broadband capacity • Create flexible, locally-driven postsecondary options • Improve partnerships between community colleges, universities, and employers Arizona Rural Policy Forum 2007 – Final Report 12 As previously noted, a lack of access to postsecondary education poses significant workforce training challenges. Although Arizona has a robust and vital community college system, not all counties (and communities) are served. All groups recommended the expansion of community college services, either through site-based instruction or distance learning technologies. They concurred that community colleges need to play the principal role of educator/trainer in rural areas; often by default, employers become educators, vis-à-vis “on the job training.” However, employers do not want to be (or have resources to be) educators. Proposed solutions included the creation of additional community college service districts, combining adjacent service districts, and/or improving broadband capacity to facilitate instructional delivery via the Internet and videoconferencing. Groups acknowledged that distance learning could be very effective, but many/most rural communities lack the broadband capacity, equipment, and resources to train their residents. The groups generally recognized the necessity for flexible curricula and instructional delivery, based upon the specific training needs of each community/region. As one participant stated, “The system must be flexible enough to serve tribal communities and very rural areas.” This flexibility would need to fully accommodate cultural and socioeconomic diversity. Arizona’s three universities’ roles and the importance of establishing effective partnerships with the community colleges were recognized. Suggestions included expansion of university satellite campuses, enhancing 2+2 programs, and implementing flexible instructional delivery strategies in rural communities. For example, universities could use high schools and community colleges for facilities and infrastructure; this model is underway in Nogales with the University of Arizona, and is emblematic of NAUs Statewide Programs. Comprehensive data driven solutions via applied research • Maintain an understanding of the marketplace to determine what is needed • Examine and analyze demographic data and labor market statistics • Create mechanisms to capture and share available resources; focus on sharing information All participants observed that workforce training initiatives are difficult to effectively plan and implement without valid, reliable, and understandable information. Furthermore, there is a discernible need to develop methods of communication and information sharing between local communities and among industries. Arizona Rural Policy Forum 2007 – Final Report 13 Very few rural communities possess research resources, other than the Internet and local libraries. Several groups identified the Arizona Rural Policy Institute as a key player— providing research, identifying resources, and acting as an advisory partner for strategic planning. Local needs drive regional plans for collaborative solutions All groups identified a need for rural communities to “act regionally” in the development and implementation of workforce training plans. They acknowledged that many funding sources (specifically, the Arizona Department of Commerce) paid closer attention to initiatives resulting from comprehensive regional plans that encompassed specific training needs of local communities. Moreover, there are currently smaller windows of opportunity for education and training grants. Successful proposals require proactive and comprehensive planning. A somewhat divergent perspective asserted that current planning is fragmented and needs to be reinvented under a statewide strategy for workforce development. Legislature to re-examine funding formulae throughout P-20 As one of the most common points of consensus among all six groups, the Arizona Legislature needs to consider other factors besides enrollment growth in the determination of budget allocations across the educational spectrum. As one group stated, “it’s critical to change the mindset of the Legislature from regarding education as something that should be funded with as little as possible to realizing the importance of public educational institutions in training the workforce.” Participants also asserted that variable costs of instructional delivery (e.g., increased costs associated with rural and remote campuses; health professions have higher costs per Full Time Student Equivalent [FTSE] than liberal arts) warrant variable funding. The groups also recommended that Arizona’s Legislature increase funding for rural Joint Technical Education Districts (JTED’s). Furthermore, greater legislative focus and support on preschool/early childhood development was strongly encouraged. The Forum’s Workforce Training discussion can best be summarized by these participants’ remarks: • Education is a national concern, a state responsibility, and a local function. Arizona Rural Policy Forum 2007 – Final Report 14 • Best practices in workforce training include providing comprehensive programs that train youth and prospective/incumbent employees with a variety of skills that can be used in various types of jobs. • The most successful training programs will lead to certificates and/or degrees. • It is particularly important to motivate youth to stay in school. Arizona Rural Policy Forum 2007 – Final Report 15 Challenges, Solutions & Opportunities — Recruitment & Retention of Health Care Professionals in Rural Arizona The six breakout groups discussed the issues, and arrived at a number of conclusions. Of the dozens of suggestions, six stood out as common to several of the groups. These solutions included: • Improve the health professions pipeline; • Enhance training opportunities (including continuing education for incumbent; practitioners and specialized/technical training); • Expand current telemedicine networks for diagnostics treatment and training; • Comprehensive public/private partnerships for facilities, equipment and training; • Increase Student Residencies in Rural Communities; • Encourage State Legislature to pursue Tort Reform for malpractice. Improve the Health Professions Pipeline • More training facilities • Expanded capacity in current facilities • Subsidize instructor pay • Solicit state and private funding • Improvements in instructional delivery methods/practices • Adjust instructor requirements to consider experience • Revise reciprocity and licensure rules The number of physicians licensed to practice in Arizona determines the number that practice in rural Arizona. Steps to increase the overall number of Arizona health workers would also increase rural numbers. Increasing the number of training facilities in Arizona, as well as expanding the capacity of existing facilities, would increase the ranks of qualified health care professionals. The major roadblocks when expanding training capacity would be attaining funding and hiring new faculty. Retaining medical faculty is often difficult due to wage disparity between medical practice and teaching. Funding should be sought from both government and private entities. Suggested solutions to this problem include subsidizing instructor pay in order to make their wages comparable to those of practicing physicians. Arizona Rural Policy Forum 2007 – Final Report 16 Improvements in delivering health professions instruction were discussed. Any step that would increase the timeliness and quality of medical training would enhance the overall number of health workers, including those in rural areas. One suggestion included the use of a mannequin and virtual reality to teach students how to perform operations without putting human patients at risk. Several groups also discussed revising instructor requirements. At community colleges and universities, nursing faculty must hold a master’s degree. A nurse practicing for 25+ years would be unable to teach courses without such a degree. Adjusting requirements to consider field experience may result in more instructors. Medical workers can also come from other states. Licensure and certification reciprocity rules could be changed to make moving to Arizona more attractive to practitioners from other states. Enhance Training Opportunities • Increased distance learning • Expand community college curricula • Increase funding for community college health professions programs • Expand community colleges into non-served counties • Local training opportunities in health care institutions Rural medical workers often suffer from a lack of continuing education opportunities because they live in areas that are far from medical training facilities. The availability of training in rural areas would keep incumbent practitioners current with medical technology, and it would help convince newcomers that rural practice would not mean surrendering to less-advanced medical practices. Training would lead to career advancement, offering physicians a chance to follow a career path without relocating to acquire new skills. The two most often-cited ways of delivering these opportunities were through distance learning and community colleges. Community colleges offer a local, classroom-style learning atmosphere. Funding for classes in these facilities is generally the same across disciplines, regardless of their actual cost; state funding rates per FTSE are the same for low-cost liberal arts majors as they are for higher costs (per FTSE) health professions. Increasing funding for medical education courses would enable more classes to be offered. The same changes mentioned above (subsidizing instructor pay, adjusting instructor Arizona Rural Policy Forum 2007 – Final Report 17 requirements) would also improve opportunities for continuing education. Expanding community colleges into counties currently lacking services/facilities is also important. Training within health care institutions, such as hospitals and clinics, would provide unique opportunities for improving staffing in rural areas. The idea behind this practice is that training people who currently live in rural areas may be more beneficial than attempting to attract outsiders. By providing local training options to local residents, institutions would employ more community members and reduce the risk of losing employees to higher-paying areas. Keeping the training local would also reduce risks that arise when young people leave town for college and not return to their home communities. Expand current telemedicine networks for diagnostics treatment and training • Expand telemedicine networks to reach more areas • Increase current network capacities • Telemedicine for training • Telemedicine for diagnostics and treatment Rural health professionals and their patients benefit immensely from telemedicine technologies. Already deployed through several networks in rural Arizona, telemedicine has the potential to offer diagnostics, treatment, and training virtually anywhere in the state. Using digital imaging and real time video conferencing, a doctor can diagnose a patient hundreds of miles away. Benefits of this technology include delivery of services to geographically isolated areas that may chronically lack health care providers. Telemedicine networks also effectively deliver training to doctors and others. Many benefits of continuing education are available through telemedicine networks. Expanding both the scope and capacity of these technologies will benefit rural Arizona. Arizona Rural Policy Forum 2007 – Final Report 18 Comprehensive public/private partnerships for facilities, recruitment, and training • Cash contributions and other forms of funding • Developer incentives to construct medical facilities • Collaborate to attract, welcome, and support new practitioners • Private funds for enhanced training of staff • Community rezoning to encourage private treatment • Public health awareness • Educational resources • Private hospitals assist in funding education • Workplace health education • Private sector assistance in introducing health education into schools • Community college links with private hospital/medical care organizations • Encourage employees of businesses to utilize local hospitals • Magnet facilities Partnering with private enterprise was cited repeatedly as an essential strategy for recruitment and retention. Businesses have a direct interest in the health of their employees and customers, and thus an interest in adequate local health care. The majority of these strategies involve facilities, recruitment, training, and public awareness. Private employers might be convinced to donate funds that would improve local health care facilities. These improvements would offer potential practitioners a more enticing opportunity, and that payback would be adequate health care for employees. Local governments can also encourage private companies to develop facilities. Tax incentives, such as rebates and credits, often serve to encourage private business development. Rezoning areas to allow for the building of private hospitals and clinics is another approach. One of the best ways that private companies can partner with the public is through community support when new medical workers are being recruited. Creating a supportive atmosphere that practitioners and their families see as comforting is important when competing for limited workers. Retention of these workers is also important and the private sector can help sustain an attractive quality-of-life. Arizona Rural Policy Forum 2007 – Final Report 19 Contributions by the private sector, including cash and in-kind donations for training facilities, can improve training resources. This can include links between community colleges and private professional hospitals. Private donations could lead to improved training and higher increased capacity. Private hospitals can also fund students’ education, solving dual problems of funding for students and placement for communities. Similar efforts by state governments are often effective, which also bodes well for local/grassroots activities. Businesses can encourage their employees to use local medical resources. They can conduct health awareness programs among their employees, with the desired outcomes of healthier workers, fewer long-term health problems, and lower insurance premiums. Private enterprise could also fund public health courses and classes in public education with equivalent outcomes. Individual health care organizations have the opportunity to seek designation as Magnet Facilities/Hospitals. This designation is attached to the top one percent of health care organizations (based on established benchmarks of excellence), and facilities that earn it are generally successful in attraction and retention of quality employees. Several facilities in Arizona, including Verde Valley Medical Center and Flagstaff Medical Center, are attempting to attain this status. Increase Student Residencies in Rural Communities • Rural rotations • Rural internships • Rural residencies • Cultural education Evidence shows that students who reside in rural areas at some point during their education are more likely to choose rural practice than those who do not. This includes people who were raised in rural areas as well as those who were served in rural settings during their schooling. A variety of rural-based programs and internships can be used to familiarize students with their options. Rotations in rural areas have proven to be a sufficiently effective approach in other states. The same is true of graduates who take up residencies in rural areas. Arizona Rural Policy Forum 2007 – Final Report 20 Due to the success of a rural internship program at the University of Arizona, a statewide policy of mandatory rural rotations was suggested. The theory behind such an approach is cultural education for the practitioner. Potential urban doctors may have an uninformed view of rural areas, seeing them as culturally backward. It may be necessary to redefine “rural” to include more than current connotations. Encourage State Legislature to Pursue Tort Reform for Malpractice • Malpractice award caps • Subsidized malpractice insurance premiums • Revolving Recruitment Fund (funded by malpractice award set-asides) Panelists were concerned that malpractice suits presented a major barrier to physician activity in rural Arizona. The risk of lawsuits decreases the number of free and discounted services rural doctors are willing to provide low-income patients. To protect their practices, physicians must pay high insurance premiums. The groups identified a number of solutions to these problems. If the Arizona Legislature placed a cap on the amount of malpractice awards (as the Texas Legislature did in 2003), insurance premiums would likely drop. Although many people identify negative results of the award cap, premiums dropped by 14% after the Texas law was enacted. Another potential way to overcome the problem of high insurance premiums is to subsidize them. Another suggestion was to allocate a percentage of all malpractice awards to a revolving fund which would then be used in recruitment efforts. While not reducing the cost of insurance, this action would, hopefully, facilitate the replacement of physicians who leave communities due to high overhead expenses. Any of these actions would require champions for advocacy to policy makers. Some possibilities were noted, including the collaborative efforts of the health care industry, health care educators, health care providers, local communities, and health insurance companies such as Blue Cross/Blue Shield. Additional Suggestions Beyond these high-consensus strategies, groups discussed a number of other ideas. • Support Retaining rural practitioners means providing them with sufficient community support. Loan forgiveness, perhaps in excess of programs already in place, was one thought. Others suggested Arizona Rural Policy Forum 2007 – Final Report 21 sharing resources among communities. Support in the form of more “health extenders,” such as allied health professionals and paraprofessionals, would alleviate some of the workload often associated with general practice. Along these same lines, some suggested finding ways to mitigate the burden of business and office needs, allowing doctors to focus on treating patients. Families of medical professionals must also be satisfied with their quality-of-life in order for a long-term relationship between health care providers and communities to develop. A stronger K-12 system would certainly make a difference. Employment and social opportunities for practitioners’ spouses are also important. • Preventive Care Other suggestions also took a different approach to the problem of too few doctors, focusing on preventive medicine. Prevention would decrease future demand for services, thus mitigating problems associated with a shortage of medical workers. These efforts would focus on education and active prevention through schools and workplaces. In schools, physical education and health classes would educate young people on the benefits of good health and offer them a regular routine of physical activity; these concepts would also be important in the workplace. Health education in both public and private jobs would be justified through subsequent lower health care premiums. These actions would minimize the need for specialized care, and thus save money, in the future. • Early intervention Following examples set in other states, Arizona could focus on young students by providing early intervention classes/training throughout their educational years. A suggested program would approach young students through youth organizations, such as Girl Scouts, and counsel/assist them throughout high school, college, and medical school. Also, improving student preparation, should they chose medical school upon entering college, is another option. Increasing requirements in math and science courses would help students attain the educational background they would need to be successful in medical school. Arizona Rural Policy Forum 2007 – Final Report 22 • Further suggestions Some participants suggested amending the current recruitment scope to include more experienced professionals, rather than focusing primarily on new graduates. Others mentioned that increasing the cap for foreign professionals on J-1 visas would certainly bring more physicians to the state by allowing more foreign students to pursue their graduate medical training in the United States. Several groups mentioned that increased efforts to market current programs would raise awareness, and make those efforts more efficient. Additionally, in consideration of Arizona’s rich and robust ethnic diversity, culture-specific, or “alternative” sources of medicine must be addressed. For example, tribal/traditional healers may perform rituals and ceremonies specific to indigenous and Latino populations. Often, these health care methods are ignored by conventional caregivers, insurance companies, and the various State Boards (Nursing, Medical Examiners, etc.). The dominant health care system in Arizona might better serve its customers by including such alternative methods (e.g., those performed by Medicine Men, Curanderas, Promatoras, etc.) among the array of available (and reimbursable) services. Panels reached many helpful conclusions, and hopefully, with these insights, rural Arizona will have a medical workforce that will keep pace with its growing population. Arizona Rural Policy Forum 2007 – Final Report 23 Conclusion The 2007 Arizona Rural Policy Forum provided a catalyst for further advocacy and action in resolving the challenges associated with workforce training, affordable housing, and recruiting & retaining health care professionals. The 149 participants engaged earnestly and collaboratively in productive dialogue, setting the stage for the next steps of advocacy and implementation. In Fall 2007, the AZRDC will identify and prioritize initiatives that can be realistically accomplished (or lead to accomplishment) within a reasonable timeframe. However, the Council is not capable of attaining unilateral “victories;” numerous organizations and individuals will be contacted and recruited to execute specific tasks. Arizona Rural Policy Forum 2007 – Final Report 24 APPENDIX Arizona Rural Development Council Mr. Charlie Thompson, Chair Manager, Rural Community Development Arizona Public Service PO Box 53999, MS 8010 Phoenix, AZ 85072 602-250-2888 charles.thompson@aps.com Dr. Sheila Harris Director Arizona Department of Housing 1110 West Washington Street, Suite 310 Phoenix, AZ 85007 602-771-1007 sheilah@housingaz.com Mr. Mike Ortega, Vice Chair Cochise County Manager 1415 Melody Lane Bisbee, AZ 85603 Phone: 520-432-9200 mortega@co.cochise.az.us LOCAL: FEDERAL: Ms. Debbie Broermann Grants Management Director HUD SW Office of Native American Programs One North Central Avenue, Suite 600 Phoenix, AZ 85004 602-379-7198 deborah_s._broermann@hud.gov Mr. Eddie Browning State Director U.S. Department of Agriculture – Rural Development 230 North 1st Avenue, Suite 206 Phoenix, AZ 85025 602-280-8701 eddie.browning@az.usda.gov STATE: Mr. Bill Bolin Rural Development Director Arizona Department of Commerce 1700 W. Washington, Suite 420 Phoenix, AZ 85007 602-771-1232 602-616-4200 cell billb@azcommerce.com Arizona Rural Policy Forum 2007 – Final Report Mr. Richard Adams President/CEO Bullhead Regional Economic Development Authority 1848 Hwy 95, Suite 104 Bullhead City, AZ 86442 928-704-6374 rlabceda@frontiernet.net Ms. Jane Bristol Economic Development Director City of Prescott PO Box 2059 – 201 South Cortez Street Prescott, AZ 86302 928-777-1275 jane.bristol@cityofprescott.net Mr. Sheldon Miller Executive Director Graham County Chamber of Commerce 1111 Thatcher Boulevard Safford, AZ 85546 928-428-2511 director@graham-chamber.com NONPROFIT: Ms. Kerry Blume President United Way of Northern Arizona 1515 E. Cedar Ave., Suite D Flagstaff, AZ 86004 928-773-9813 kblume@nazunitedway.org 25 Ms. Carla Roberts Vice President of Affiliates Arizona Community Foundation 2201 East Camelback Road, Suite 202 Phoenix, AZ 85016 602-381-1400 croberts@azfoundation.org PRIVATE: Ms. Angie Harmon Community Affairs Specialist Freeport McMoRan Copper and Gold, Inc One North Central Avenue Phoenix, AZ 85004 602-366-8009 angie_harmon@fmi.com Mr. Marty Laurel Vice President for Community Relations Blue Cross Blue Shield of Arizona 8220 North 23rd Avenue Phoenix, AZ 85201-4872 602-864-4324 mlaurel@phx1.bcbsaz.com Mr. Lee Randall General Manager Apache Gold Casino Resort P.O. Box 1210 San Carlos, AZ 85550 800-272-2438 ext 3616 leerandall@agcrr.us TRIBAL: Mr. Royce Jenkins Director Office of Community Planning & Economic Development The Hopi Tribe P.O. Box 123 Kykotsmovi, AZ 86039 Phone: (928) 734-3241 Royce_Jenkins@hopi.nsn.us Arizona Rural Policy Forum 2007 – Final Report Mr. Derrick Watchman Vice President JP Morgan Chase Bank, N.A. Native American Banking PO Box 71, Mail Code AZ1-1178 Phoenix, AZ 85001-0071 602-221-6406 derrick.watchman@chase.com AT-LARGE: Mr. Dave Castillo Senior Deputy Director Fannie Mae Arizona Business Center 400 E. Van Buren, Suite 325 Phoenix, AZ 85072 602-744-6843 dave_castillo@fanniemae.com Ms. Cathy Connolly 127 E. Echo Lane Phoenix, AZ 85020 602-997-4865 cconnolly7@cox.net Ms. Shawn Dralle RBC Capital Markets 2398 E. Camelback Road, Suite 700 Phoenix, AZ 85016 (602) 381-5362 shawn.dralle@rbcdain.com Mr. Wayne Fox, Assistant Dean The W. A. Franke College of Business Northern Arizona University NAU, Box 15066 Flagstaff, AZ 86011 928-523-7323 wayne.fox@nau.edu Mr. Michael Proctor, Assistant Dean College of Agriculture and Life Sciences University of Arizona Forbes 306 Tucson, AZ 85721 520-626-5531 520-419-2942 mproctor@arizona.edu 26 COUNCIL OF GOVERNMENTS/ADVISORY: Mr. Rich Gaar Executive Director SouthEastern Arizona Government Organization (SEAGO) 118 Arizona Street Bisbee, AZ 85603 520-432-5301 rgaar@seago.org Mr. Richard Kuczek Director Western Arizona Economic Development District (WAEDD) 224 South 3rd Avenue Yuma, AZ 85364 928 -217-7116 Richardk@WACOG.com Mr. Ken Sweet Executive Director Northern Arizona Council of Governments 119 E. Aspen Ave Flagstaff, AZ 86011 928-774-1894 ksweet@nacog.org Staff Ms. Pat Schroeder, CED Executive Director, AZRDC P.O. Box 4036 Phoenix, AZ 85030 480-892-2569 480-229-8781 cell patschroeder@cox.net Mr. Craig Ringer Deputy Director Central Arizona Association of Governments (CAAG) 1075 S. Idaho Rd. Ste. 300 Apache Junction, AZ 85219 480-474-9300 cringer@caagcentral.org Arizona Rural Policy Forum 2007 – Final Report 27 Panel Chairs & Recorders PONDEROSAS Panel Chair: Shawn Dralle Managing Director RBC Capital Markets 2398 E. Camelback Rd., Ste. 700 Phoenix, AZ 85016 Phone: 602-381-5362 / Shawn.dralle@rbcdain.com PINONS Panel Chair: Dave Castillo Senior Deputy Director Fannie Mae Arizona Business Center 400 E. Van Buren, Ste. 325 Phoenix, AZ 85007 Phone: 602-744-6843 / dave.castillo@fannie.mae.com Recorder: Justin Weaver Legislative Research Analyst Arizona State Senate Capitol Complex 1700 W. Washington Phoenix, AZ 85007 Phone: 602-926-3171 / jweaver@azleg.gov Recorder: Brian Lockery Legislative Committee Analyst Arizona House of Representatives 1700 W. Washington St., Suite H Phoenix, AZ 85007 Phone: 602-926-5526 / blocker1@azleg.gov ASPENS Panel Chair: Sally Odette Senior Community Development Consultant Arizona Public Service 400 N. 5th Street, MS 8010 Phoenix, AZ 85004 Phone: 602-250-4240 / Sally.odette@aps.com PALO VERDES Panel Chair: Mike Ortega County Administrator Cochise County 1415 Melody Lane, Bldg. G Bisbee, AZ 85603 Phone: 520-432-9200 / mortega@co.cochise.az.us Recorder: Jennifer Anderson Legislative Committee Analyst Arizona House of Representatives 1700 W. Washington St., Suite H Phoenix, AZ 85007 Phone: 602-926-4586 / janderson@azleg.gov Recorder: Bill Boyd Legislative Research Analyst Arizona State Senate Capitol Complex 1700 W. Washington Phoenix, AZ 85007 Phone: 602-926-3171 / bboyd@azleg.gov JUNIPERS Panel Chair: Bill Bolin/Tom Doyle Rural Development Director Arizona Department of Commerce 1700 W. Washington, Ste. 420 Phoenix, AZ 85007 Phone: 602-771-1232 / billb@azcommerce.com SYCAMORES Panel Chair: Kathy Turner Director of Investments United Way of Northern Arizona 1515 E. Cedar Drive, Ste. D Flagstaff, AZ 86004 Phone: 928-773-9813 Recorder: Leah Birk Legislative Research Analyst Arizona State Senate Capitol Complex 1700 W. Washington Phoenix, AZ 85007 Phone: 602-926-3171 / lbirk@azleglgov Recorder: Megan Gnagy Legislative Research Analyst Arizona State Senate Capitol Complex 1700 W. Washington Phoenix, AZ 85007 Phone: 602-926-3171 / mgnagy@azleg.gov Arizona Rural Policy Forum 2007 – Final Report 28 2007 Forum Participants Richard Amanda Belinda Reid Chris Peggy Louise Frank Kerry Bill Douglas Jane Debbie Brent Kevin Eddie Dave Hong Kathleen J. T. Carol Becky Yvonne Sheila Jim Terry Thomas Shawn Ellen Suzanne Eric Ken Sandra Timothy Dan Jodie Rebecca Wayne Richard Vanezza Steve Christina Adams Aguirre Akes Alvina Bavasi Belknap Bilagody Blume Bolin Bristol Bristol Broermann Brown Brown Browning Castillo Chartrand Corak Cotter Curtis Daggett Delgadillo DeVoe Heidman Donahue Doolittle Doyle Dralle Drew Drum Duthie Edes Ernst Perez Ernster Field Filardo Flanagan Fox Gaar Gallego Gervais Gomez Arizona Rural Policy Forum 2007 – Final Report Bullhead Economic Development Authority Regional Center for Border Health, Inc. Eloy Chamber of Commerce Navajo Health Foundation/ Sage Memorial Hospital Office of Navajo and Hopi Indian Relocation Northland Pioneer College To'Nanees'DIzi Chapter United Way of Northern Arizona Arizona Department of Commerce Yavapai Regional Medical Center City of Prescott HUD-SWONAP Governor's Office Flagstaff Unified School District USDA Rural Development Fannie Mae AZ Dept Health/Health Systems Development Coconino Community College City of Safford Coconino Career Center Friends of Flagstaff's Future Nogales Community Development Cochise College Grand Canyon State Electric Cooperative Association Pinal County Arizona Department of Commerce RBC Capital Markets Rural Community Assistance Corporation SEAGO Town of Taylor City of Williams Delta Dental AZ Foundation City of Bullhead City Town of Quartzsite City of Sedona US Housing Urban Development WA Franke College of Business SouthEastern Arizona Governments Organization Nogales Community Development Arizona Public Service City of Douglas 29 Victor John Raquel L. H. Kimball Angie Sheila Joseph Richard Jac Deb Mignonne Jules Todd Joyce Helen Judee Robert James Royce Mike Fred Joanne Gary Michael Kara Michael Robert Carl Akos Jeffrey Richard Michael Marty Rick Ingrid Sherri Tracy Roy Priscilla Lauren Matt Greg Gonzalez Grahame Gutierrez Hamilton Hansen Harmon Harris Haughey Heffernon Heiss Hill Hollis Holzgrafe Honyaoma Hospodar Hudgens Ferrell Jackson Jackson Jayne Jenkins Johnsen Karnas Keene Kellogg Kelly Kelty Kerski King Kinney Kovach Kros Kuczek Lainoff Laurel Lavis Lee Lee Lenartz Lingo Littlefoot Bernally-Long Lore Lucero Arizona Rural Policy Forum 2007 – Final Report City of Douglas Coconino County, SEDI Leadership & Organization Development Consulting Cochise County Facilities Management Freeport-McMoRan/Phelps Dodge Phelps Dodge Arizona Department of Housing City of Flagstaff ASU-Morrison Institute for Public Policy CAVIAT Coconino County Cochise College Show Low Chamber of Commerce Hopi Tribe Rural Health Office, UA MEZCOPH BOTHANDS, Inc. Arizona Public Service City of Casa Grande Navajo County Public Works The Hopi Tribe Arizona Public Service Arizona Department of Housing Coconino County Partnership For Economic Development Arizona Community Foundation City of Flagstaff City of Flagstaff Arizona Community Foundation Arizona Housing Finance Authority City of Holbrook League of Arizona Cities and Towns Western Arizona Economic Development District NAU - Center for Business Outreach Blue Cross Blue Shield of Arizona AZ Cotton Growers Association Coconino Community College Arizona Department of Commerce AZ Dept Health/Health Systems Development Cochise County Workforce To'Nanees'DIzi Chapter Navajo Health Foundation/ Sage Memorial Hospital League of Arizona Cities and Towns Santa Cruz County 30 Kim Todd Tom Chris David Cindy Mike Colleen Stephanie Tuly Daryle Mandy Brian Jen Sheldon Richard Randy George David Mark Bruce Lloyd Sally Michael Arthur Jan Julie Bruce Lynn Anthony Donna Richard Mike Lee Tom Alvina Everett Jean Roberto Carla Casey Joe Carol Lunt Madeksza Manos Marko Maurer May McElmury McGregor McKinney Medina Melvin Metzger Mickelsen Miles Miller Morrison Nelson Nerhan Newlin Nexsen Nordstrom Notah Odette Ortega Othon Parsons Pastrick Pavlikowski Perez-Hewitt Peterman Phipps Polheber Proctor Randall Rankin Reid Rhodes R. Bowman Rios Roberts Rooney Sanchez Sanger Arizona Rural Policy Forum 2007 – Final Report Lunt Farms County Supervisors Association of Arizona Maricopa County Rural Community Assistance Corporation Prescott Chamber of Commerce Arizona Public Service Arizona Public Service AZ Dept Health/Health Systems Development Greater Flagstaff Economic Council Regional Center for Border Health, Inc. Indian Health Service, Hopi Health Care Center Diablo Trust City of Cottonwood Mohave County Graham County Chamber of Commerce Attorney at Law AWC SBDC Town of Huachuca City City of Holbrook City of Lake Havasu Nordstrom & Associates Office of Planning and Evaluation Arizona Public Service Cochise County Arizona Public Service Arizona Public Service Flagstaff Chamber of Commerce Sheehy Enterprises Inc Copper Corridor Economic Development Coalition Kayenta Township Commission Arizona Public Service Carondelet Holy Cross Hospital University of Arizona - CALS Apache Gold Casino Resort Town of Florence NHF/SMH Project CENTRL Northern Arizona Building Association Arizona Department of Commerce ACF/AZRDC City of Cottonwood Economic Development Gila County Upper San Pedro Partnership 31 Richard Kathy Gary Rick Ken Deb Rafael Carl Charles Mike Kathy Nils James Fabian Fred Derrick Molly Jim Will Robert Annette Searle Smith Smith Swanson Sweet Sydenham Tapia Taylor Thompson Townsend Turner Urman Valenzuela Valle Warren Watchman Williams Wine Wright Yazzie Yurchak Arizona Rural Policy Forum 2007 – Final Report Cochise Co. Board of Supervisors Willcox Chamber of Commerce and Agriculture Unisource Energy Services City of Flagstaff NACOG Arizona Department of Commerce Arizona Department of Commerce Coconino County Board of Supervisors Arizona Public Service Coconino County United Way of Northern Arizona City of Nogales Arizona Public Service AZ Dept Health/Health Systems Development Rural Community Assistance Corporation JP Morgan Chase Bank, Native American Banking NAU Advancement City of Flagstaff County of Graham To'Nanees'DIzi Chapter Small Business Development Center 32 Key sponsors APS Arizona Community Foundation Blue Cross Blue Shield of Arizona Arizona Lottery Freeport McMoRan Copper and Gold, Inc. Partners Arizona Association for Economic Development Arizona Cattle Growers Association Arizona Cotton Growers Association Arizona Department of Commerce Arizona Department of Housing Arizona Farm Bureau Arizona Governors Office Arizona Rural Development Council County Supervisors Association of Arizona League of Arizona Cities and Towns Maricopa County Industrial Development Authority The W. A. Franke School of Business at Northern Arizona University The Rural Community Assistance Corporation The United States Department of Agriculture – Rural Development Arizona Rural Policy Forum 2007 – Final Report 33