Remarks to the 32nd Annual Rural Health Conference

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by HRSA Administrator Mary K. Wakefield

May 8, 2009
Miami Beach, Fla.

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Thank you for that introduction. It's wonderful to be with you again.

I want to take a moment to acknowledge the NRHA and the great work they do for you and with you in Washington, D.C.

I also want to acknowledge the Office of Rural Health Policy staff here today. Under Tom Morris' terrific leadership I can say from the helm of HRSA – this group is the best of the best.

If there's an opportunity to move the puck down the ice on behalf of rural health, it doesn't matter the time of day or day of the week – they're in there scrapping. I can't imagine rural health being better served. They're all nice here, but they're a force back there. We're so fortunate to have them at HRSA.

And let me give a shout out – that's not a phrase we use much in North Dakota, but they'll know what I mean – to my colleagues from back home who I miss a lot. I wish they'd all come to Washington – but then who'd be left in the state?

I'm very proud to represent you, and to bring additional rural health orientation to the federal government and all Americans, as HRSA Administrator.

When the offer to take the job came from the White House, I was honored. It was a challenge I knew I had to accept. The path of my life's work – primarily in nursing and in rural health care and public policy -- had trained me for it.

I had to accept because we know that 50 million people in rural areas across America face challenges every day accessing health care.

We know that people who live in rural communities have higher rates of poverty and lower rates of health insurance coverage. We know that they suffer in greater numbers from health problems and chronic diseases like obesity, diabetes and cancer.

Where else but as HRSA Administrator would I have an opportunity to try to elevate and address these problems? HRSA's programs touch on all of them: access to care, distribution of the health care workforce, prevention. It's all in HRSA.

And I have to tell you, there's a shift in how we operate at HRSA and how HRSA is perceived at the White House and on Capitol Hill. You can sense it. There is a ton of new energy in the agency. You can read major newspapers and trade press and start to see references to our little-known agency. And suddenly our senior staff is being called upon for their expert opinions on a whole range of subjects germane to reform.

The Administration is committed to our programs, as I'll tell you in a minute, and I want you to know that you can expect a lot from us. As I tell the HRSA staff – we're pushing the refresh button. It's a new day.

This past Monday, for example, I participated in a discussion on rural health care at the White House with Nancy-Ann DeParle, director of President Obama's new Office on Health Reform. Nancy-Ann is the President's point person on everything related to reform.

And, as an aside, I'm pleased that both [NRHA President] Denny Berens [NRHA CEO] Alan Morgan were there, engaged in the discussion and bringing NRHA's expertise to the table.

During the meeting, we listened to the concerns of Americans living in rural areas as they told about the challenges they face in holding on to health care. And we heard what all of you already know: that despite the persistence of rural Americans in trying to get the health care coverage they need, the system just isn't accessible or affordable enough. They need help. All Americans do.

In connection with that meeting, Nancy-Ann's office released a report called: “Hard Times in the Heartland,” which looks at health care in rural areas and spells out the need for change. You can find it at: www.healthcare.gov.

And let me squeeze in a program note in before I go too far. We expect to release $14 million in FY 2009 Rural Health Outreach grants very shortly, so watch the HRSA News Room site for that announcement.

Today, I want to tell you how HRSA fits into President Obama's agenda for national health care reform and give you a better idea of what HRSA plans to do with the infusion of funds we received through the Recovery Act.

Not in a very long time has there been so much optimism that the United States will finally, and comprehensively, reform our health care system.

The President set the nation on a new course in health care on Feb. 4, just two weeks after taking office, when he signed the Children's Health Insurance Reauthorization Act of 2009. That action expanded health care coverage for children from low-income families from 7 million to 11 million.

And with his signing of the American Recovery and Reinvestment Act two weeks after that, the President put HRSA squarely in the middle of his effort to rebuild the health care system.

President Obama has said he wants “affordable, high-quality health care for all Americans within one year,” and judging by the pace he's setting for all of us, I think he means it.

The Recovery Act allotted $2.5 billion to HRSA. Of that, $2 billion is targeted to health centers, half of whose grantees serve rural areas.

• On March 2 we announced the release of $155 million in grants to fund 126 new health center sites;
• On March 27 we sent $338 million to our 1,100 current health center grantees to extend the hours and current services and add staff to deal with the crush of new patients.
• Last Friday, May 1, we announced the availability of $850 million for all current health centers to improve and expand physical sites, buy needed equipment, and pay for and implement health information technology. Later this summer, we'll announce a competition for additional Recovery-related health center capital funds.
  
  HIT is a big part of the health center investment, and the Department has another $2 billion that they'll use to spur greater use of HIT across the nation. And you can be sure that HRSA will pay special attention to the HIT needs of rural hospitals and communities.

The sheer size of President Obama's health center investment – $2 billion over two years – shows that he wants HRSA to make an immediate difference in the lives of our 17 million – and rapidly rising – health center patients.

Okay, that covers $2 billion of the $2.5 billion.

HRSA's remaining $500 million in Recovery Act funds will be used for investments in workforce development:

• $300 million will go to the National Health Service Corps to effectively double its field compliment. That's more than 3,300 doctors, dentists, advanced-practice nurses and other professionals who will receive help in paying their student debts in exchange for their service in some of our neediest communities.
  
  In 2007, the NHSC placed 55 percent of its clinicians in rural areas, so this represents another enormous boost to rural health care made by President Obama. Inside HRSA, we're hard at work to streamline our application and placement practices to get more candidates into the Corps and into the field as quickly as possible. We know this $300 million isn't enough to solve the problem of too few rural providers, but it's a good downpayment to get the people we need and help keep vital infrastructure in place.
• The other $200 million will be invested in Title VII and VIII health professions programs, with an emphasis on nursing. We expect these funds to flow quickly to colleges and universities to build instit utional capacity and support qualified students.

Taken together, the “pass-through” impact of this half-billion-dollar boost in the ranks of health professionals will help slow more than a decade of shrinking Primary Care-related education and service programs. It won't solve all of our problems, but it will buy us some time.

The President's workforce investment shows clearly that he understands we're in the teeth of a workforce shortage crisis – an estimated million nurse deficit and 89,000-physician shortfall by 2025, a third of them in Primary Care.

The workforce problem is particularly acute, and getting worse, in rural America, where seven out of 10 of our shortage areas are located. That's 33 million residents without access to basic health care.

Yesterday afternoon Secretary Sebelius, along with the HHS agency administrators, rolled out the President's 2010 Budget, which is why I didn't get here until last evening. I can now tell you that the Budget includes over $1 billion to support a wide range of programs to strengthen our nation's health care workforce – investments to expand scholarships and loans for providers willing to practice in medically underserved areas.

This funding will enhance the capacity of nursing schools, improve access to oral health care through dental workforce development grants, target minority and low-income students, and place greater emphasis on ensuring America's senior population gets the care and prescriptions they need. The full details on the Administration's funding request for HHS can be found online.

Money is needed, of course, but it's not enough by itself. We have to change the way we operate in clinical settings. We are entering an era in which clinicians will be called upon to practice in fluid rather than static environments, with greater emphasis on providing care for chronic conditions.

Furthermore, we have to re-emphasize cultural competence. For example, Latinos are now the biggest minority group and the fastest-growing segment of the U.S. population, and immigrants from Africa, Asia and the Caribbean have arrived in great numbers in recent decades.

So it isn't just about supply of providers – it's about supply of providers with essential, needed skills and knowledge.

We also recognize that we need to collect better data on the health care workforce. The White House has pulled HRSA in to talk about the rural implications of health care reform, and our Office of Rural Health Policy's research centers have been preparing relevant data and reports and they've been pivotal. We've done some other work recently on physicians and pharmacists, but we want to improve our capacity to target agency investments.

On the workforce front, we have two initiatives you should be aware of:

• First, a Web-based Health Workforce Information Center that we think is on its way to becoming the must-see resource for all workforce questions. 4,500 people visited this one-stop shop for health professions information on the first week it opened in January, and now, on average, 1,860 users are visiting each week. Feel free to contact my old staff at UND at healthworkforceinfo.org.
• Additionally, HRSA is sponsoring a meeting August 8-10 called “The Healthcare Workforce Crisis:  A Summit on the Future of Primary Care in Rural and Urban America.” We're planning on 600 national experts for this conference – ranging from HRSA grantees to academicians and policymakers – and I expect that some of you will be among them.

A last word on the budget. The President shares your belief in the need to improve access to health care and improve the quality of health care in rural areas. So you don't see proposed cuts to our ORHP main program lines, and in some cases you see additional resources brought to the table – from outreach grants to state offices to telehealth grants.

There's much, much more in this budget that directly and indirectly impacts rural health and I know you'll be hearing more about it and you can review it for yourselves. With that, let's look beyond yesterday's budget release to what's next in health care reform.

All of you here in this hall know that we have deferred health reform too long. We can't wait any longer. President Obama wants Congress to send him a reform package he can sign this year, because he knows families need help, especially those who have lost their jobs and their health insurance.

The President is committed to supporting a health care reform proposal that:

• Reduces costs for families, businesses and government;
• Guarantees that people have their choice of doctors, hospitals and health plans; and
• Assures affordable, quality health care for all Americans.

Discussions over health reform have focused on themes such as expanding access, preventing disease, and strengthening primary care.

All of those issues resonate deeply in rural communities.

I also think health care reformers can learn a few things from rural areas.

Where else but in the delivery of rural health care is necessity so truly the mother of invention? Where else is working together and finding new ways of doing more with less so much a part of the delivery of health care?

We have many lessons that urban areas could learn from. In my home state of North Dakota, a telepharmacy project funded by HRSA is restoring corner drug stores to towns that had lost them. And it's creating new jobs as well, about 60 so far. Several years ago the legislature passed a bill allowing drugs to be distributed by registered pharmacy technicians whose actions are viewed in real-time by pharmacists at remote locations. Computer conferencing technology lets the pharmacists see the prescription, the stock bottle where pills are stored, and the label on the bottle the patient takes home. And before the patient leaves, the pharmacist – by law – has to consult him or her, in a nearby private room. According to data collected to date, error rates in the project are lower than the national norm.

That's the kind of innovation and intelligence rural practitioners can bring to health care reform. Bigger isn't always better. Rural is nimble, we're efficient. We can turn on a dime. We have lessons to teach, and many contributions to make to the path of reform.

And I'm not the only one who thinks so. A March report on innovation in rural health care by Grantmakers in Health says that health professionals in rural areas “have demonstrated a collaborative culture … and a readiness to be creative that … are crucial for providing superior and cost-effective services.”

The report goes on to say that “rural workforce shortages drive the creation of new or enhanced roles for health care personnel and team approaches to care.” If you haven't seen the report, I'd suggest it merits a review.

We're working at HRSA to address issues like rural shortages, but we need to keep on being creative and resourceful.

The article concludes by saying that rural innovations in the delivery of health care “result in access, efficiency, quality, care coordination, rapid learning, cooperation and lower spending, and offer ideas and techniques that could usefully be adapted to other rural places and to urban health systems as well.”

Grantmakers in Health – calling out rural health care as the headwaters of innovation, not some backwater.

Didn't know you were that fabulous, did you?

As you can tell, HRSA has a lot of work and we're pushing on three big fronts. First, we have to continue and strengthen the day-to-day work of the agency. Second, we are rolling out the President's Recovery Act. And third, we will have a contribution to make in health care reform. We look forward to your wise counsel and positive contributions across all of that.

When President Obama addressed his health care reform summit on March 5, he said: “Every voice has to be heard. Every idea must be considered…there should be no sacred cows. Each of us must accept that none of us will get everything that we want, and that no proposal for reform will be perfect.”

There is a veritable herd of sacred cows – multiple special interests – that are pushing against reform, so this is a more than challenging endeavor.

However, the President was equally clear when he said that only one option is not on the table: the status quo.

We need your help to keep the status quo off the table. Rural America and the rest of America can't afford more of the same.

Going forward -- many of you know me, and you know how I've always operated: as someone who tries to bring everyone to the table. I want to work together with you in real partnerships. I've found that when that happens, key leaders emerge who push forward viable solutions.

I'll continue to look forward to learning from organizations like NRHA. After all, you're not just my old friends; you represent millions of people who rely on HRSA programs. We want to hear your ideas. We're inviting all of our stakeholder groups in to meet with us.

We're looking forward to partnering with you and other groups to push the notion of putting people first, of working to meet the health care needs of vulnerable populations.

We're also reaching out to our sister agencies at HHS like CMS and AHRQ to develop new and better ways of working together.

And about a month ago, when I traveled with Vice President Biden to North Carolina to award a new health center grant, I took advantage of the trip to discuss possible avenues of cooperation between HRSA and the Department of Agriculture with Secretary Tom Vilsack, who also made the trip.

As I told you at the beginning of my remarks: It's a new day! It's not the same old, same old anymore at HRSA…

I'm also listening to and learning from folks on the front lines: psychologists and pharmacists, caregivers in HIV/AIDS clinics, public health and so on.

And I'm hearing a lot from HRSA's employees about how we're doing – I'm inviting them and frankly expecting them to tell me how we could do things better. Like you, their expertise is terrific. It spans the decades.

President Obama captured the spirit of these times during his campaign last year, when he said: “This is our moment.”

These are the times we've been preparing for. We are on the verge of wide-ranging reform, and health centers and HRSA and organizations like NRHA are key players. It's our time.

We have the responsibility. And we have the needs of our fellow Americans in mind. The President was right: “We are the people we've been waiting for. We are the change we seek.”

Thank you for listening and thank you for all that you do.