Remarks to the 35th National Primary Care Nurse Practitioner Symposium

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by HRSA Administrator Mary K. Wakefield

July 16, 2010
Copper Mountain, Colorado

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Thank you for that kind introduction – and thanks to all of you for coming to this gorgeous setting here today. It is literally breathtaking.

I’m especially pleased to be able to speak with you at a time when our health professions workforce – and nurse practitioners – are finally getting long-deserved recognition for the essential contribution they make to the health of our nation. I can attest to this personally, as my health care provider for the past eight years has been a nurse practitioner.

As we all know too well, this hasn’t always been the case. The attention and recognition of workforce challenges writ large and support for nurse practitioners specifically has too often been anemic, reflected most obviously in funding – or lack of it – for health care professions. This administration is working hard to change that, starting with the 2009 appropriations request for HRSA’s primary care, health professions, maternal and child care, and rural health programs, all of which jumped considerably from previous funding levels.  This was followed by the American Recovery and Reinvestment Act, and the $2.5 billion infusion of funds for HRSA to expand our health center program and strengthen the health care workforce.

In this context, nurse practitioners have the opportunity not only to more fully help meet our nation’s changing health care needs, but also to reaffirm the contributions of advanced practice registered nurses within our health care system. 

The fact that President Obama appointed a nurse from North Dakota to lead HRSA demonstrates his recognition of nursing as a source of expertise to help guide key health care programs and policies.  And I am happy to say that I’m not the only nurse to serve in a senior position. Today, you will find more nurses in senior executive positions in the federal government than perhaps at any other time in recent memory. Most recently, Marilyn Tavenner, also a nurse, was named principal deputy administrator of CMS. She was at the helm of CMS until the last couple of days, when Don Berwick was sworn in, but she will continue in her significant role to make very important contributions.

HRSA is another excellent example: Three of our bureaus are headed by nurses: the Bureau of Health Professions, the HIV/AIDS Bureau and the Office of Regional Operations. Two of them were appointed during my time at HRSA.

Let me turn your attention to health care and the Affordable Care Act.

Every day, we hear more news about the ACA, along with quite a bit of misinformation, but Americans are gradually becoming more familiar with the general provisions of this historic piece of legislation as implementation ramps up. And we are on track to make these reforms a reality for all Americans.

On July 1, a new government website, healthcare.gov, was launched where everyone can find the full range of public and private health insurance plans available to them based on their individual circumstances. If you haven’t checked it out, do, so you can talk to your patients, colleagues, and students about what’s there. Also beginning July 1, Americans who have been denied insurance coverage because of a pre-existing condition can now apply for insurance through high-risk insurance pools. This is a key ridge to help people now, even as HHS moves to stand up the health care exchanges in 2014.

But the question a lot of people keep asking me, and it’s a very good one, is: “How is the ACA going to affect primary care?”

In fact, from my vantage point, the ACA is all about primary care. The ACA’s key provisions are perfectly in sync with the goal of primary care, which is better health for all. You can’t obtain better health without primary health care, and our track record of dismal investments in preventive and primary care parallels this nation’s less-than-stellar performance on key health indicators.

Now I would like to focus on how the ACA affects HRSA’s programs and your profession in particular when accomplishing two of its key goals:

1. Increase access to primary care services and
2. Invest in the health care workforce.

One of the strategies embedded in the Affordable Care Act aimed at increasing access to primary care is to create the largest expansion of community health centers in the program’s history. It provides $11 billion in funding over the next five years for the operation, expansion and construction of health centers throughout the nation. 

That will make it possible for HRSA-funded health centers to double the number of patients they serve annually to nearly 40 million.  The number of health center sites has now grown to more than 7,900 across the country.  And remember, health centers serve everyone who enters their doors, regardless of their insurance status or ability to pay.  About 40 percent of center patients have no health insurance.  Charges for services are set according to income, and only nominal fees are collected from the poorest patients.

It is difficult to imagine how we would have risen to the health care challenges posed by the recent economic downturn without the 15,000 nurses – a third of them in advanced practice – who work in health centers.  A wave of new patients poured into health centers as people lost work, and with it, their health insurance.

Looking forward, it will be impossible to answer the new challenge of essentially doubling the patient base over five years without incredible contributions from thousands more nurses.

For nurses, a doubling of the health center patient base not only means thousands of new nursing jobs, it means more nurse administrators, more responsibility, greater autonomy.

But the health center network isn’t the only HRSA program with a wealth of opportunities for nurses.

The Affordable Care Act also expands the National Health Service Corps, many of whose clinicians worked in health centers before the reforms.  The NHSC also benefited from the Recovery Act, which steered $300 million to the program to expand the number of clinicians who work in underserved areas.

The Corps offers debt servicing of student loans in exchange for service by primary health care professionals in high-need areas and in health centers.  For decades, the Corps has proven to be one of America’s best assets in extending primary health care to people who need it most.  And their ranks will grow by thousands over the next few years.

Let me pause here to make a quick pitch for the NHSC, which helps finance the education of nurse practitioners, psychiatric nurse specialists and certified nurse-midwives.  Of the more than 4,800 NHSC clinicians currently in the field, 15 percent are advanced-practice nurses. But we have standing vacancies for 1,700 more at 1,400 locations across the country.

Health care professionals who sign up with the Corps serve a minimum two-year term in underserved areas.  In exchange, they receive up to $50,000 in student loan repayments.  Nurses who choose a five-year commitment can get up to $145,000 in loan repayments.

The President is very committed to this program and intends to carry through on his promise to double the size of the Corps to some 8,000 practitioners over the next seven years. And since the program is run by HRSA, I aim to deliver on that promise.

If you know nurses who might be interested, please tell them about the NHSC and urge them to visit www.hrsa.gov to learn more.

Through programs like the Corps and community health centers, and the new home visiting program we’re launching with five states, we accomplish a critical part of HRSA’s mission: to help make sure that we have the right kinds of health care professionals serving in the right places – places where they can do the most good for the most people.  With these funds, we will be able to increase training opportunities and build infrastructure for a future generation of health care professionals. 

Beyond these very important investments in access to primary care, the ACA will also have a significant impact on the health professions.

As you probably know, HHS Secretary Kathleen Sebelius recently announced that $250 million will be used to bolster the primary care workforce.  These funds will:

• Encourage 600 nurse practitioner students to pursue full-time careers by 2015;
• Invest in 10 nurse practitioner-led, nurse managed health centers that provide comprehensive primary health care services in medically underserved communities, important training grounds for nurse practitioner students;
• Support primary care training for 600 new physician assistants; and
• Create residency slots for 500 new primary care physicians by 2015.

These Affordable Care Act funds will help address the shortage of primary care providers and recognize that nurse practitioners should play a critical role in meeting this shortage. 

Nurse practitioners are the fastest-growing group of primary care professionals in the country, and Nurse Managed Centers are a model for delivering nurse-led care.  Nurse practitioners and advanced practice nurses provide more than 40 percent of the care at health centers. In the last fiscal year, HRSA funded 21 Nurse-Managed Centers across 13 states (for a total of $7 million) to support health care for underserved populations and to train 2,270 undergraduate and graduate nursing students.

In FY 2009, HRSA funded 206 advanced practice nursing programs and spent over $34 million dollars for more than 3,000 students in 110 NP programs and more than 1,000 students in 15 nurse midwifery programs.

As I mentioned earlier, this is a great time for nursing and HRSA’s nursing programs. Under the Affordable Care Act, reform is interlocked with primary care services, including those that you provide. We see nursing-specific investments designed to ensure growth and expansion – after decades of lean funding and staffing shortages.

The Act also reauthorizes and significantly amends all seven of HRSA’s nursing programs – which represent the primary source of federal funding for nursing education.

All of you know that schools of nursing have long endured shortages of doctoral prepared faculty – and faculty shortages are the biggest reason that more than 50,000 qualified nursing applicants each year are turned away.

The Affordable Care Act addresses this shortage by updating the Advanced Education Nursing Traineeship and the Nurse Anesthetist Traineeship Programs. Previously, we were prohibited from granting more than 10 percent of this funding to doctoral students. The Act eliminates this cap. 

Support for training in advance education practice is also highlighted in the Nursing Workforce Diversity program.

Similarly, the Nurse Faculty Loan Program provides funds for schools to offer loans to master's or doctoral-level nursing students interested in becoming teachers.  The combination of increased FY 2010 appropriations and additional funding from last year’s Recovery Act means this program is significantly larger now than it has been in years. The ACA increased the maximum annual amount of individual loans from $30,000 to more than $35,000 for FY2010 and 11.

Additionally, the Nursing Student Loan Program helps alleviate the nursing shortage by giving students with limited financial resources access to long-term, low-interest loans.  It also provides partial loan cancellation for nurses working in shortage areas.

The Affordable Care Act also increases the amount students may borrow by almost 25 percent – to a maximum of $17,000.  In the 2008-2009 academic year alone, HRSA was able to provide over $27 million for more than 12,000 new loans.

Finally, the Nurse Education, Practice and Retention Grant program was updated to emphasize a renewed focus on quality.  With the need for continual assessment and improvement of quality standards in healthcare delivery systems, nurses will need a strong background in the science behind high-quality nursing care.

The ACA also expands primary care and other services in many ways. For example, it strengthens the health care safety net and prevention initiatives for women and children. I alluded to this earlier:

• It provides $100 million in FY2010 for a Maternal, Infant, and Early Childhood Home Visiting Program for states to provide evidence-based home visitation services to improve outcomes for children and families who reside in at-risk communities. Nurse practitioners were key players in this initiative.
• It requires coverage for evidence-based preventive care and screenings guidelines for infants, children and adolescents. This is a very important piece of legislation that actually values data-driven health care approaches. It is refreshing.
• It reauthorizes the Emergency Medical Services for Children Program. Established in 1984, it is the only federal program specifically focused on improving pediatric emergency care to reduce childhood morbidity and mortality due to severe illness or injury. The ACA authorizes $25 million for the program in FY2010, increasing to $30.4 million in FY2014.
• It extends Family-to-Family Health Information Centers – non-profit organizations that help families of children and youth with special health care needs and the professionals who serve them.

The ACA also strengthens and expands HRSA’s 340B Drug Pricing Program, which requires pharmaceutical drug manufacturers that participate in the Medicaid drug rebate program to enter into pricing agreements that provide discounts on covered outpatient drugs purchased by certain public health safety net facilities.  At present, 14,500 covered entities and 800 pharmaceutical manufacturers participate in the program.  The Affordable Care Act will enable 5,000 additional entities to participate.

 The Affordable Care Act adds to the list of covered entities that are entitled to discounted drug prices to include certain children’s and freestanding cancer hospitals excluded from the Medicare prospective payment system; critical access and sole community hospitals; and rural referral centers. 

In the area of trauma care, which I know some of you are involved in, the ACA authorizes $100 million for three new programs to award grants to qualified public, nonprofit Indian Health Service, Indian tribal, and urban Indian trauma centers. It also establishes a program of grants to states to promote universal access to trauma care services provided by trauma centers and trauma-related physician specialties. 

The list of reforms is long. And the overall impact of these changes, I think, will be a continuation of the positive trends reflected in HRSA’s recent Nursing Survey – which found that the profession is growing, that nurses are better educated than ever before, and that they’re becoming more diverse, more representative of the populations we serve. However, we still have much more work to do in the area, especially in attracting more Hispanics, Asians and African Americans into the nursing profession.

Experiencing health care reform from up close has convinced me that we have a once-in-a-lifetime chance to make a monumental difference in the health care of our nation. Social Security didn’t come easy, Medicare didn’t come easy, and the Affordable Care Act hasn’t come easily, but it’s critically important.

Our profession is receiving support as never before, and we are being called upon to play a larger role than ever before. 

Our mission today is fundamental to the professional calling of every nurse: to provide access to high-quality health care for all Americans.  Over the years, our shared values have helped us accomplish a lot – in our practices, in our professional associations, and in conducting and disseminating research.

I also want to drive home the importance and value of contributions being made by nurses and nurse practitioners – not only to the health of the nation through clinical practice, teaching, or research -- but also in bringing their expertise in the public policy arena. We need nursing at the table – some have said we need them most of all.

You are a vital link between patients and distant policymakers in federal and state capitals, between health care policies and real-time conditions on the ground.  Your opinion and your expertise matter.

In other words, health and health care is our work, and health care policy must be part of our work, too. 

Let me end not with my own words, but with those of the President, who spoke about the importance of nurses saying: “In hours of need, in moments where people are most vulnerable, most worried, nurses are there, doing difficult and lifesaving work.  America’s nurses are the beating heart of our medical system. You’re on the front lines of health care in small clinics and in large hospitals, in rural towns and in big cities, all across America.”

He also said: “as a father, as a husband, I will forever be in debt to the women and men of your profession.” I wholeheartedly agree. The President is not unlike many Americans who recognize the value of nurses in the care they and their families receive.

Thank you for listening and for taking time out of your hectic schedules to be here today.  We at HRSA, this administration, and I personally, appreciate all you do – in your many roles and in the many places you hail from – to advance the health of the nation.