Remarks to the 9th Annual Conference on Urban Health

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by HRSA Administrator Mary K. Wakefield

June 18, 2010
New York, New York

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Thank you, Jose (Sanchez, LMSW, LCSW, vice-president Generations Northern Manhattan Health Network) for that kind introduction – and thanks to all of you for coming out this morning.

Hailing from North Dakota, driving in from LaGuardia was certainly a “You're-not-in-the-Great-Plains” Moment for me. Then again, I grew up in the 7th largest municipality in my home state – population, about 7,200 – so by North Dakota standards, I'm from the Big City.

I've been asked to talk today about how healthcare reform will advance health equity – specifically, how does the recently passed Affordable Care Act address issues that have been on the national agenda, frankly, since President Teddy Roosevelt first called for reform?

Eighteen presidents and almost a century later, in terms of the Nation's health and health care, we are living in historic times, indeed.

This morning, I'm going to address the question on the table through the lens of the work that my agency does.

Known as HRSA, the agency has front-line responsibility for many of the investments envisioned by the Obama Administration under the Affordable Care Act – as well as those already made under last year's Recovery Act. Both are very much about advancing health equity.

Together, these two pieces of legislation – ARRA and the ACA – represent the most significant steps forward for underserved and vulnerable populations in recent memory – and a monumental opportunity to begin to address some of the more daunting challenges we face on the health equity front.

Not the least of these challenges has been the long-deferred and now more urgent necessity of building a healthcare workforce adequate to the needs of the American people – providers with the needed skill and knowledge sets, in the places people need them most.

Just two days ago, we announced the release of:

• $168 million to expand the number of primary care residency slots in community settings to produce 500 additional providers by 2015;
• $32 million to train 600 physician assistants;
• $30 million to boost the number of nurse-practitioners by 600 clinicians – and $15 million more to support 10 Nurse-Managed Health Centers, a training and clinical care innovation that pre-dates the Affordable Care Act, but is strengthened in it. I'll talk more about this in a moment;
• And $5 million to encourage states to promote local health workforce strategies that best address their local shortage needs through planning and implementation activity.

This announcement, of course, is just an arrow in the quiver in terms of what it will take to fully address our primary care workforce shortages.

I should also be clear that HRSA invites, wants and needs more partners. Virtually everything we do is based on networks and cooperative agreements. We are known as “The Access Agency” – or the “Safety Net Agency.” But we might just as well be called, “The Health Care Partnership Agency…”

In terms of meeting our mission, there are very few examples where HRSA goes it alone.

Let me give you just one quick illustration: In the Bronx today, there are more than 150 Census Tracts that are experiencing widespread shortages of healthcare professionals – whole neighborhoods where there are few, if any, doctors, dentists, nurse mid-wives, or accessible counseling services.

HRSA serves the Bronx and hundreds of other communities in collaboration with a variety of organizations – very few of which are anywhere near the size of the New York City Health and Hospitals Corporation, parent of the Generations Northern Manhattan Health Network. Last year, HHC received $22 million in federal grants, for 35 service programs at 14 sites citywide.

The potential for dramatically expanding these partnerships is now possible under the Affordable Care Act for the first time in decades, as we'll see in a moment.

For those who might not be familiar with HRSA as a division of the U.S. Department of Health and Human Services, we are responsible for managing a $7.8 billion portfolio of 80 programs through a competitive grant-making process involving more than 3,000 recipient organizations.

We are, of course, best known for supporting a national network of 1,100 Health Centers, which operate more than 7,900 clinical sites.

Those grantees provide hands-on primary care to nearly 19 million patients without regard to their ability to pay. In fact, 9 out of 10 health center clients are living at or below 200 percent of poverty; four out of 10 are uninsured; a million are homeless; one of every three is a child.

In New York State last year, HRSA health center grantees received almost $191 million dollars for these and other services.

More than half of those funds ($111 million) went to support more than 240 health center sites in the five boroughs of New York City, as well as services rendered by other providers, including Generations Northern Manhattan.

This “profile” is relatively consistent with our national numbers, as well.

Of all of our health center grantees, urban and rural, about half (47 percent) are concentrated in the nation's cities. And virtually all of those urban grantees received some portion of the $2 billion that President Obama and Congress invested in expanding primary care under last year's Recovery Act.

That funding paid for 127 new or expanded health centers; additional staff hiring; an increased range of services; and longer hours of operation to help blunt the affect of the Recession on families in need.

To give you some sense of perspective – a platform for much of the intent of the ACA -- here's what the Recovery Act achieved:

• The single largest annual increase in new patients seen in the Health Centers – 1.6 million – in the 45-year history of the program – and be mindful that the vast majority are uninsured and medically vulnerable;
• The largest staff recruitment and retention effort ever accomplished in such a short period of time: more than 1,200 new clinicians hired nationwide;
• $3.2 billion in related economic activity – on $2 billion in Recovery investments – generated in local communities during the economic downturn.

This growth set historic benchmarks virtually across the board, even as we were instituting improved quality-assurance measures and accountability systems; new Health IT systems; new reporting requirements; and a reorganized network of regional offices to promote and improve collaboration on best practices among our grantees.

All of this was done within a Health Home Model – with all primary care services under one roof, including dental, mental, pre-natal, pediatric and geriatric health services, and much more – at an average cost per patient of about $600, much less than the cost of care in other settings.

Now, imagine what it might mean to double the size of that system in the next six years.

That's what the Affordable Care Act aims to do: double the patient base of the community health centers to as many as 40 million patients by the year 2015.

Before I get into some details of the Act, I want to finish sketching how these pieces fit together with HRSA's other programs to promote and support a comprehensive Health Home Model….

Here are a few better known illustrations:

• HRSA's Maternal and Child Health program provides nearly $800 million in block grant funding to states, counties and local governments to reduce infant mortality and improve the health of 34 million women and children. In all, about 60 percent of all expectant mothers in the U.S. receive supplements, counseling and primary care through this program – often at HRSA-supported Health Centers;
• HRSA also manages the Ryan White HIV/AIDs program, which provides $2.3 billion annually for primary care and life-sustaining medications to about half the people living with the virus in the U.S. at 900 mostly urban clinical locations nationwide. Many of these grantees are also health centers, providing yet another example of the alignment of resources in an integrated care system;
• HRSA also oversees the 340B drug discounting program, which provides negotiated savings on a long list of prescription drugs to more than 14,000 safety net providers. Savings to patients nationwide amount to $2 billion annually. Among participating providers are critical access hospitals; dialysis and hemophilia clinics; and, yes, our Health Center grantees – and many other providers who qualify as federal “look-alikes.”
• Finally, training the next generation of health professionals is critically important. Much has been written and said about the coming workforce shortages, and those are real concerns. But the Recovery Act provided $500 million in increased funding to expand college admissions; boost faculty staffing levels; and provide greater scholarship and academic debt relief for clinicians willing to work in underserved areas.

And the Affordable Care Act has many related authorities and some built-in funding that assures higher spending levels for the next several years.

The better known of these HRSA-managed training programs, through ARRA and ACA – Title VII and VIII of the Public Health Service Act, and the National Health Service Corps – already are supporting 12,000 students in primary care training, while doubling the size of the Corps.

Health care professionals who sign up with the Service Corps serve a minimum two-year term in underserved areas. In exchange, they receive up to $50,000 in student loan repayments – with additional payments for extending their contracts – all while working as salaried clinicians. We've also dealt in a part-time option this year that allows practitioners to extend their payback period.

If you know anyone who might be interested, please tell them about the NHSC and urge them to visit www.hrsa.gov to learn more. We are currently accepting applications for Recovery Act funds through July 29 of this year – or until those funds are exhausted.

The NHSC certainly is important to urban underserved populations and communities – as forty percent of participating clinicians historically have taken urban assignments, about half of them in Health Centers.

HRSA has other programs, as well, but these four examples – Maternal and Child Health; Ryan White; 340B; and workforce training – give you a pretty good idea of some of the programs that are important to the underserved. And all of them, except Ryan White, are part of the Affordable Care Act.

As an aside, if we add all of these grant-funding streams together, New York State received $658 million last year in HRSA support – $300 million of which was awarded to institutions and organizations in New York City.

Now, I want to briefly describe how all of these pieces fit together to improve access and outcomes – and I'd like to do it by telling you the story of just one fragile patient population to illustrate the point:

About 20 years ago, the U.S. Congress authorized a small program known as Healthy Start, amid concern that the infant mortality rate in this country had frozen at an unacceptably high level.

Today, Healthy Start has 104 grantees and a $105 million line item in the HHS budget – because the data HRSA compiled over those early years showed that Healthy Start works.

By providing early intervention; nutritional supplements; and lifestyle counseling to expectant high-risk mothers – and assisting them in getting into primary care Health Homes – our grantees were able to blunt an epidemic that some feared was beyond hope or help.

We are not talking about marginal improvements when we have data from 38 states, the District of Columbia and Puerto Rico that show:

• Zero infant deaths among Healthy Start clients in 22 jurisdictions over the past two years, despite vastly different demographic and socioeconomic conditions on the ground – from Jacksonville, Fla. to Flint, Mich.; from Philadelphia, Pa. to Los Angeles, Cal.; in Wichita and St. Louis; San Antonio and Fresno; and 14 other reporting areas in between… ZERO!

Clearly, infant mortality is still unacceptably high in this country. But we have proven strategies that have shown it is reducible; and our grantees have shown the power of coordinated, targeted care to address decades-old issues of health equity – even in populations residing in complex urban environments.

So now that we have a sense for how these various programs fit together – and how the Community Health Centers and related provider organizations act as dispensaries of high-quality, affordable care – let's take a look at a few concrete examples of what the Affordable Care Act adds to the picture:

• Doubling the patient base of the Community Health Center system -- which already is the largest primary care network in the nation, public or private – to 40 million patients by 2015;
• Expanding grant authority to include Nurse-Managed Care Centers to address an expected shortage of at least 22,000 primary care physicians – and possibly twice that number – over the next decade;
• Funding up to $200 million to build or expand school-based health centers, another care model that we know works;
• Funding up to $1.5 billion in new grants over the next six years to increase home visits to expectant mothers in high-risk communities;
• Directing a review of the shortage area formulas used to designate underserved communities for key programs, health center funding and National Health Service Corps eligibility; under our current federal definition there currently already are at least 2,000 of these communities in U.S. urban centers;
• Reauthorizing and significantly amending all seven of HRSA's nursing workforce programs -- which represent the primary source of Federal funding for nursing education – to both rapidly increase nursing faculty and diversity within the profession.
• Providing tax relief for those health care professionals who practice in underserved areas as a condition of receiving student loans under state programs. These providers now qualify for a refund on their 2009 federal income tax returns, as well as an annual tax cut. And some may qualify for retroactive tax exclusions on their prior year return. The IRS is working this out now.

So, yes, the list is long.

We should also be mindful of the complex mandates at work here.

The expectations for us are that we work to meet the needs of extremely diverse patient populations, and that diversity is accelerating, in communities as widely different as the desert borderlands of the Southwestern United States; the tribal homelands of the Dakotas and Alaska; the bayou parishes of Louisiana; and the housing projects of Chicago, New York, Philadelphia, Miami, Houston and Los Angeles.

HRSA supports services to 150,000 residents of public housing alone. And in rural communities, a HRSA-supported clinician is often the only care provider available for miles around.

We focus like a laser on:

• improving the health of economically disadvantaged and geographically isolated urban and rural communities;
• promoting the adequacy and equitable distribution of the health care professions, and increasing minority representation in them;
• and we do this by building networks of care and cooperative relationships with committed people on the ground who know best how to serve their unique communities – people like those in this room today.

The opportunity to achieve those aims – which I know are shared by everyone here – has never been greater than it is right now, I think, thanks to the dogged determination of the President and the members of Congress who supported the Affordable Care Act.

Thank you!