Remarks to the Institute of Medicine

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by HRSA Administrator Mary K. Wakefield

July 13, 2009
Washington, D.C.

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Thank you, Dr. Fineberg (IOM President Dr. Harvey Fineberg), for that generous introduction and the invitation to be here today.

As most of you know, the collaborative relationship between IOM and the Health Resources and Services Administration extends back many years; and, at one time or another, virtually all six HRSA Bureaus and 14 Offices have been involved with IOM in joint efforts.

Beyond the 2001 Quality series, dozens of other studies and conferences have engaged this partnership across an array of issues important to HRSA – and we have benefited by the IOM's expertise. Here are just three or four examples to illustrate the point:

• Addressing the Dentistry Shortage Crisis, and structural problems with the delivery of pediatric oral health services;
• Developing a process for assessing possible causes of V accine Injuries – which may be particularly important going forward, given the H1N1 vaccine preparations underway;
• Safeguarding children from the spillover effects of Parental Depression; and refining Pregnancy Weight Gain guidelines, for example.

Again, this is just a partial inventory.

From my personal vantage point, during much of my career in health care, I have been involved with HRSA programs, both inside and outside government – inside as staff to an appropriations member, outside associated with academic institutions that draw on HRSA programs. The point is, I thought I had a pretty good handle on it when I accepted this appointment back in February.

But I quickly discovered that it's almost easier to describe what HRSA doesn't do, than it is to enumerate all of the critical functions it performs and the populations and dimensions of health care delivery it serves – from critical access hospitals, which constitute about a third of all hospitals, to nurse-managed clinics. Our populations include organ transplant donors, new mothers, infants, HIV/AIDS patients… it's a long list.

We all know about the Community Health Centers, of course. There are 7,500 HRSA-supported clinics nationwide, providing primary care to more than 17 million patients regardless of their ability to pay – which constitutes the largest client population in any sector of the U.S. health system today, public or private.

You may also know that the agency's HIV/AIDS Bureau oversees the only national treatment program that touches half of the people in the U.S. living with the virus.

And HRSA's Maternal and Child Health Bureau, which has historic roots dating to the early decades of the last century, continues to work to improve the health of mothers and children.

But HRSA also funds and oversees an almost bewildering array of lesser known federal functions that help fill important – albeit less frequently discussed -- gaps in our fractured Health Care delivery system. Among these critical HRSA efforts are:

• the national Poison Control Network;
• the national Organ Transplant Network;
• one of the country's largest prescription drug discounting programs – known to some of you as the 340B program – which delivers life-sustaining medication to millions of people living with such conditions as hemophilia through 14,000 different entities, including disproportionate share hospitals and Community Health Centers;
• a multimillion-dollar portfolio of scholarship and student loan repayment programs for primary care professionals;
• a health care shortage tracking service, which also monitors the health care workforce nationwide; and
• the National Health Service Corps, which provides thousands of doctors, dentists and nurses for some of the most geographically remote rural communities and economically distressed urban neighborhoods in the Nation.

In all, HRSA runs a $7.2 billion operating division of HHS, overseeing 80 different programs that provide funds to 3,000 discrete organizations for hands-on care, mental health and addiction counseling, pre-natal supplements and screening, clinician training, research and much more. All with a staff of about 1,400 people, in a little-known agency.

But the bottom line is that if it involves at-risk populations – migrant workers, the homeless, public housing residents, poor pregnant women, the uninsured – HRSA has a hand in it. The agency connects with about 24 million people nationwide.

One third of those patients are kids.

With the exception of the Veterans' Administration , there is probably no other single agency of the U.S. Government that has as much experience as HRSA in supporting frontline Primary Care. Most of what we do involves Primary Care. Our grantees are predominately in Primary Care.

So the linkages between the agency's principle functions and some of the conversations around where Reform should move health care are numerous, to say the least.

The Nation is, for example, in the teeth of a workforce shortage issue – a nursing deficit and a primary care physician shortfall. Making a meaningful contribution to addressing this challenge is squarely on HRSA's agenda, as well.

This scarcity of providers is particularly acute, and getting worse, in rural America, where seven out of 10 of our shortage areas are located. There are 33 million rural residents who face persistent barriers to basic health care. And a significant urban underserved population. In terms of reengaging science, I'd say we're operating in something of a data-free zone here.

On top of targeting efforts in these programmatic areas, we also are tasked with addressing the impact of the economic downturn on HRSA's programs and population base.

More than 6 million people have lost their jobs since the economy first went south in 2007 – and in many instances, they also lost their health insurance. Half of all Americans with homes in foreclosure are citing medical problems as a contributing cause, and we are fast approaching 46 million uninsured.

With very few exceptions, like my home state of North Dakota (which finds itself with a generous budget surplus), State budgets across the nation are fracturing. And safety net programs are being tightened.

Again, this has major implications for HRSA programs and the populations we serve. Federal funding for programs ranging from our network of state Office of Rural Health to our Poison Control Centers and Ryan White HIV/AIDS clinics are threatened by current economic circumstances, as States struggle to maintain their share of the costs.

Our Community Health Centers have over 100,000 employees in a collection of care settings that have thousands of clinical vacancies at any given time – even as we right now are absorbing 300,000 new patients.

Many of the components being discussed in the context of Health Care Reform – including Health Information Technology, Prevention, and Care Coordination – are already well established models (or under development) in many HRSA-supported care dimensions.

Across a wide range of care facilities – including HRSA's Healthy Start programs targeting economically disadvantaged women and their newborns -- our grantees have managed to wring efficiencies from a lean system of care to keep per-patient annual costs to less than $600, while ensuring health outcomes that rival other ambulatory care centers.

This, in a care delivery setting in which four out of 10 patients are uninsured, and nine out of ten are below 200 percent of poverty.

So, it shouldn't have come as any surprise that one of President Obama's first official acts was to invest $2.5 billion in HRSA under the Recovery Act – to double the size of the National Health Service Corps; dramatically boost funding for nursing education; and expand and upgrade the health centers, many of which have been in operation for decades.

As an aside, you may be interested to know that within two weeks of the Service Corps opening its application cycle to fill the new Recovery Act field positions, 2,300 clinicians registered for the program and 1,400 filed formal applications.

So even in these tough times, the spirit of altruism still does exist out there; what it needs to flourish is a vehicle to do so.

In 2000, HRSA was a $4.8 billion agency. But thanks to the Stimulus Funding now flowing through it in this time of national emergency – and with health care costs playing such an enormous role in the economic downturn -- HRSA is now a $9.5 billion public trust.

So, as we push the refresh button at HRSA on behalf of the populations we serve – under the direction of new Administration – we at HRSA are very much looking forward to continuing the meaningful work conducted in partnership with IOM.

Thank you.