Remarks to the Vanderbilt School of Nursing, Centennial Lecture Series

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by HRSA Administrator Mary K. Wakefield

June 2, 2009
Nashville, Tenn.

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Thank you, Colleen (Conway-Welch), for that introduction, and thanks to the Vanderbilt School of Nursing for inviting me to speak. Congratulations on reaching your 100 year anniversary. That is a landmark achievement and I’m honored to be part of your celebration.

At the Health Resources and Services Administration, we’re proud to contribute to the work you do through our Advanced Education Nursing, Nurse Education, Practice and Retention, and Innovative Nurse Education Technologies grants. Together, those funds total almost $1.6 million – a strong financial partnership between the Vanderbilt School of Nursing and HRSA.

I want to take a minute to tell you a bit about my background. I want to tell you more about HRSA and how it fits into President Obama's health care reform plans. And I’ll give you my personal view on what reform could mean for nurses.

Thinking broadly, these are exciting times. Difficult, possibly even a bit perilous in some ways, but exciting. In the span of our lives, we have rarely seen so much optimism, so widely held, that the United States will finally, and comprehensively, reform our health care system.

Pieces of the platform are already being put into place, as evidenced in the improvements in America’s health and well-being that have occurred since January 20:

• On Feb. 4, just two weeks after taking office, President Obama reauthorized the Children’s Health Insurance Program to expand health care coverage for children from low-income families from 7 million to 11 million. That’s a crucial advance in the struggle to ensure that all children have access to health care.
• Two weeks after that, he signed the Recovery Act, which invested an additional $2.5 billion in HRSA’s health center and workforce programs. And which will invest billions more in health information technology to improve the delivery of care and cut medical errors everywhere.
• And a few weeks ago, by setting new mileage standards for future automobiles, President Obama did more than any of his predecessors to fight global warming and limit our dependence on foreign oil sources. That decision also will result in enormous benefits to U.S. public health in terms of reduced incidence of asthma, lung disease and cancer.

Each of these initiatives set the stage for a new day in America’s health; and, accordingly, it’s a new day at HRSA.

President Obama’s presence and actions have caused a shift in how HRSA is perceived at the White House and Capitol Hill. You can sense it. There’s a boatload of new energy in the agency. You read the New York Times and the Washington Post and see references to HRSA that weren’t there before. Along with this, HRSA senior staff is increasingly called upon for their expert opinions on a whole range of subject germane to health care and health care reform.

The difference is that the President is committed to addressing the health care needs of the populations that HRSA’s programs serve, so it’s no surprise that his Administration sees HRSA as part of the solution to the challenges we face. They expect a lot from us, and as a nurse leading this $7 billion agency I can say through a lot of hard work, we’re ready to deliver.

As I tell the HRSA staff, we're pushing the refresh button on what we do and how we do it. It's a new day.

But let me back up a bit so that you understand how I came to be at the helm of HRSA and how I think it helped prepare me.

I grew up in Devils Lake, North Dakota, population 7,000 – has anyone here been to that state? -- and began my health care career working alongside nuns and nurses in Mercy Hospital there when I was still in high school.

When I graduated, there were ample jobs in universities around the country for a nurse with a PhD, but I wanted to go home to North Dakota to be a nurse educator in my home state.

At that time there were very few PhD nurses anywhere, and even fewer in North Dakota. That meant that I had a greater ability to make a difference in a state where every single nurse and every single nurse educator mattered. That’s still the case in North Dakota and, interestingly, because of the increased demand for nurses, the need for nurse educators has recently ramped up across the nation.

Fewer nurses, and few other health care providers, meant more responsibility, but also more opportunity for nurses to provide health care and to help build a nursing workforce. As with other types of work in North Dakota, there was – and still is – little redundancy in the ranks.

That leanness forces an orientation toward creativity and innovation that sets rural health care and, perhaps, underserved urban areas apart. I think health care reformers can learn a few things from rural areas.

Based on my practice and teaching experience in the delivery of rural health care, I can tell you necessity truly is the mother of invention. Working together and finding new ways of doing more with less very much is a part of the delivery of rural health care.

I’ll give you just one example: In North Dakota, a telepharmacy project funded by HRSA is restoring pharmacy services to corner drug stores and rural hospitals in towns that had lost them. And it’s creating new jobs as well, about 60 so far. Several years ago the North Dakota state 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. According to data collected to date, medication-related 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 – new team approaches to enhance access without diminishing quality. Bigger isn’t always better. Rural is nimble, efficient. Rural practitioners can turn on a dime. Rural has lessons to teach, and many contributions to make to the path of reform.

Eventually I left North Dakota to go to Washington to work in the offices of two great Senators from my home state: Quentin Burdick and Kent Conrad.

After a decade on Capitol Hill, I went to George Mason University as director of the Center for Health Policy, Research and Ethics, before returning home to direct the University of North Dakota’s Center for Rural Health. That’s where I was when President Obama asked me to join his team as HRSA administrator.

For those of you who may not be fully aware of the work we do at HRSA, let me give you a brief summary.

• The shorthand version is that HRSA ensures the delivery of primary health care in thousands of medically and geographically underserved communities.
• But we also play a major role in training health care professionals and placing them where their talents are needed most.

Through loan repayments and scholarships – most notably in our National Health Service Corps – we offer incentives for health care providers to practice in underserved communities. I invite those of you in the audience pursuing nurse practitioner, certified nurse midwife or medical degrees to consider this program. We’re ramping it up markedly -- doubling its size through Recovery Act funds.

And, of course, we house the Division of Nursing, which administers the grants you receive and leads Federal efforts to assure an adequate supply and equitable distribution of qualified nurses around the nation.

• HRSA also provides financial and technical support to keep struggling rural hospitals open and work with them to strengthen the quality of care they provide.

Tennessee has 16 of these “critical access hospitals” in small towns across the state. All of them have 25 beds or fewer, but they are vitally important facilities in their communities. We sent more than $1.1 million this year to health care providers in rural Tennessee through our Network, Outreach and Delta grants.

• Additionally, we oversee the nation’s organ donation and transplantation efforts.
• And we play a vital role in public health through our Maternal and Child Health Bureau, which traces its lineage to the 1912 establishment of the Children's Bureau and the 1935 enactment of Title V of the Social Security Act.

Few pieces of U.S. legislation match the deeds and duration of Title V, which has helped instruct generations of Americans on issues like basic monitoring of a child’s health, proper nutrition during pregnancy, prevention of childhood injuries, and strategies to avoid sudden infant death.

And few organizations have done as much to promote the rights and health of children with special health care needs and integrate them into mainstream society as our colleagues at the Maternal and Child Health Bureau. Their contributions to U.S. public health are legendary, and their investment in your state is substantial.

This year, Tennessee received $11.7 million under Title V. Another $1.5 million was sent to Healthy Start sites in Memphis and Nashville to combat disturbingly high infant mortality rates in parts of these cities. Nursing programs from Tennessee State University and Belmont University are part of the Nashville Healthy Start partnership. The schools plan to recruit participants in the project to become nurses, with the hope that they will stay in the community to practice.

The continuing problems of poverty, poor education and limited access to care in communities like the one in North Nashville targeted by the Healthy Start grant I delivered today show us why President Obama has acted to reauthorize CHIP and expand health care services. Our health care system is broken, decisive action is needed, and President Obama is taking it!

• But let me return to HRSA and the work we do. As I said, most of it involves primary care. With the exception of the Veterans’ Administration, no other single agency of the U.S. Government has as much experience as HRSA in providing frontline primary care.

Each year one of every 18 people in the United States first seeks the help of a doctor, dentist or nurse at a primary care clinic supported by HRSA funds and expertise.

More than 7,500 HRSA-supported community health center sites provide top-quality primary and preventive health care to 17 million people, regardless of their ability to pay.

You may glimpse a vision of the future of U.S. health care by visiting a HRSA health center. With an emphasis on preventive care, on keeping close track of patients with chronic diseases, on giving patients a medical home – features of the health center model of care could be where health reform is heading.

Many of those health centers, together with hundreds of other community-based providers, also deliver primary and specialty care and life-saving prescription drugs to more than half a million people living with HIV/AIDS through HRSA’s Ryan White HIV/AIDS Program.

If it involves delivering health care to at-risk populations – the uninsured, the homeless, migrant workers, people living with HIV/AIDS, public housing residents, poor pregnant women – HRSA has a hand in it. Our programs touch 24 million people nationwide.

That’s who HRSA is. And the best way to tell where we’re headed, and to discern President Obama’s plans for primary care, is to look more closely at the Recovery Act investments, and his 2010 budget proposal.

As I mentioned earlier, 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 released $155 million to fund 126 new health center sites;
• On March 27 we sent $338 million to our current health center grantees to extend hours and current services and add staff to deal with the crush of new patients.
• On May 1, we announced our plan to make available $850 million to existing centers to improve and expand physical sites, buy needed equipment, and pay for health information technology. Later this summer, we'll have a competition for additional Recovery-related health center capital funds.

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 Americans’ lives. He wants to make primary health care available to more of the people who need it most.

And that’s already happening here in Nashville at the United Neighborhood Health Services Health Center funded by HRSA. Their CEO, Mary Bufwack, was on a telephone press conference with me and HHS Secretary Kathleen Sebelius last week. Mary said they’re using their $1.4 million in Recovery Act money to expand medical and mental health services at five current clinics and to open three new clinics in communities hit hard by the recession. That growth will create 27 new jobs, and it also allowed her to retain a counselor who works with pregnant teens and hire back a social worker and two clerks who had been laid off.

By providing preventive care to more low-income people, by giving them a medical home, and by helping more of them with chronic conditions manage their illnesses, the President’s unprecedented investment in health centers will improve the nation’s overall health. By doing so, we will cut emergency room visits and reduce the cost burden on the entire health care system.

The remaining $500 million in HRSA’s Recovery Act funds will be invested in workforce development, because the President understands that we need more health care professionals if we’re going to provide more health care:

• $300 million will go to the National Health Service Corps to effectively double its members in the field. That will put thousands more doctors, dentists, advanced-practice nurses – both nurse practitioners and certified nurse midwives -- and other professionals into our neediest communities in exchange for paying down their student debts.
  In 2007, the NHSC placed 55 percent of its clinicians in rural areas, so this represents another enormous boost to rural health care by President Obama.

• The other $200 million will be invested in Title VII and VIII health professions programs. We expect these funds to flow quickly to colleges and universities to build institutional capacity and support qualified students.

The President's investment shows clearly that he understands we're in the teeth of a workforce shortage crisis – estimates point to a deficit of 1 million nurses and 89,000 physicians by 2025.

Money is needed, of course, but it's not enough by itself. We have to change the way we operate in clinical settings. More and more, clinicians will be called upon to practice in fluid rather than static environments. And, as health centers already are doing, we have to put more emphasis on providing care for chronic conditions.

Furthermore, we have to re-emphasize cultural competence. After all, 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.

But still, supply is the first goal to meet, and the President's 2010 Budget includes over $1 billion to support a range of HRSA programs to strengthen our nation's health care workforce. These funds will:

• expand scholarships and loans for providers willing to practice in medically underserved areas;
• enhance the capacity of nursing schools;
• improve access to oral health care;
• provide more opportunity for minority and low-income students; and
• place greater emphasis on ensuring America's senior population gets the care and prescriptions they need.

Specific to nurses, the nurse loan repayment and scholarship program budget would rise to $125 million in 2010, an increase of $88 million over this year’s $37 million budget.

The budget for the NHSC would be set at $169 million, an increase of $34 million over this year's amount.

What do these two proposals tell us? One, that we need dramatically more nurses – in a hurry -- and, two, that we need to push more practitioners out as soon as possible to the locations where people are suffering from lack of access to care.

More generally, the actions of President Obama and Congress have taken to date tell us that we as a nation have:

• woefully under-funded primary care;
• woefully under-emphasized the health promotion and disease prevention activities that help people stave off chronic disease; and
• woefully under-invested in the health professions.

And those corrective actions point us toward the future of health care in the United States.

The President has said that reform should:

• Assure affordable, quality health coverage for all Americans;
• Reduce the long-term growth of health care costs;
• Invest in prevention and wellness;
• Improve patient safety and quality of care; and
• Guarantee that people have their choice of doctors, hospitals and health plans.

And in a May 15 essay in the Wall Street Journal, Office of Management and Budget Director Peter Orszag argued that the nation can move toward a high-quality, lower-cost health care system by doing four things:

• Implementing health information technology, because we can’t improve what we don’t measure;
• Doing more comparative research into what works and what doesn’t, so that treatments that don’t improve health aren’t recommended;
• Emphasizing prevention and wellness, so that people do things that keep them healthy; and
• Changing financial incentives for providers so that they are “incentivized” rather than penalized for delivering high-quality care.

The good news in these declarations for HRSA’s health centers is that they have for years been moving in the direction that President Obama and Mr. Orszag outline for the nation. In 2007, the average cost per health center patient was just $562, and cost increases at health centers over the past four years have been at least 20 percent below the national cost increase.

Health centers are accustomed to serving all who seek their services. They are invested in prevention. And for years they have been engaged in collaboratives to improve the quality of care they deliver to patients with chronic illnesses, such as diabetes, high blood pressure and heart disease. They’ve been testing what works for their patients; they’ve discarded what doesn’t, and implemented what does. They are ready to move forward confidently into the future.

And the good news for nurses is that we already do the type of things that need to be done to cut costs and improve care. We’re the health care professionals who coordinate patient care, who check back with patients to make sure they’re doing what they should to remain well, who pull health care teams together. We’re the people who give patients the personal contact they enjoy and that helps them heal.

We’re the health care professionals patients most often see and talk to first, whether they come in for a scheduled primary care visit, get prepped for surgery, or rush into an emergency room.

To patients in health care settings and to communities served through public health, nurses are the face of health care. And we can be the face of reform, too.

Just as the leanness of rural health care forces practitioners there to be creative and innovative, so too will health care reform.

Why is President Obama focusing so much attention on the delivery of primary care and on producing more nurses and other health care professionals?

Maybe because he’s seen the data coming out of Massachusetts. He’s seen a state opt heroically for full health care coverage for its citizens but struggle to find enough primary care practitioners to meet the jump in demand for their services.

There’s an opportunity here for nurse practitioners and other advanced practice nurses to be innovative, to think creatively, to make the case for more responsibility in primary care.

For example, who will be responsible for making sure everyone in a health care setting knows how to use the health information technology that’s coming?

Well, maybe it’ll be a nurse with a degree in nursing informatics from the Vanderbilt School of Nursing.

The description on your “Nursing Informatics” Web site reflects the hopes President Obama has for the new technology: “Imagine finding new connections, new solutions that... improve patient outcomes, lower costs, create new tools for teaching or patient care over the Internet.”

That’s the future everyone wants to see.

Luckily, the nation is full of examples of nursing innovation. At New York University, the College of Nursing in 2006 opened a nurse practitioner-managed primary care practice on the same site as the NYU College of Dentistry clinic for low-income patients.

Why? Because a survey of dental patients found that about half of them either had no regular primary care provider or had difficulties getting timely appointments.

With the nurse practitioners on site making referrals easy, dentists have sent hundreds of patients over for appointments. Older patients have been especially receptive to the new primary care clinic.

By co-locating care sites and building a collaboration with dentists, the NPs are helping hundreds of low-income New Yorkers access clinical care and manage their chronic ailments.

I know the Vanderbilt School of Nursing has a long history of this type of collaboration between advanced practice nurses and physicians and a long history, too, of serving the community.

Your West End Women’s Health Center is a model of service and student education, as are the other 250 nurse-managed health centers across the nation. And HRSA has been proud to support your work there with over $2 million in grants since 2001.

By emphasizing primary care, health promotion and disease prevention, and outreach and education, nurse-managed health centers also help the country move steadily toward the high-quality, lower-cost health care system that President Obama wants to see emerge from health care reform.

In his FY 2010 budget, he asked for another $37 million for the Nurse Education, Practice and Retention program from which the funds for nurse-managed health centers are competitively awarded. Now I hope you understand why I’m so optimistic and energized by this President and his vision for health care reform.

Look at it from where I stand!

I’m in charge of a $7 billion Federal agency with a host of important programs, including a network of 7,500 primary care clinics, when an increase in the availability of primary health care looms as a major component of reform.

And I’m a nurse entering a period when we’ll see not only a steady expansion in our ranks, but a probable expansion in our reach and responsibilities.

These are exciting times, aren’t they?

Thank you for inviting me to speak with you today. It has been a pleasure.