Remarks to the Rural Health Outreach and Network Development Grantees Meeting

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by HRSA Administrator Mary K. Wakefield

August 2, 2010
Washington, D.C.

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First, I want to thank all of you for taking the time to be here today, and I especially want to thank Tom Morris and the ORHP staff for planning this important meeting for our rural grantees.  ORHP has a terrific leader and a sterling team committed to health care.

It’s great to be among so many rural friends.  As many of you know, I grew up in a small town in North Dakota and began my first foray into health care as a nurse’s aide in a small rural hospital and a rural nursing home.

Across my work in rural health care and rural health policy, I’ve seen firsthand many of the challenges that you confront and I commend your dedicated hard work and commitment to rural health issues.  I hope you come away from this meeting energized with new ideas and even more motivation to expand the vital work you’re doing in rural communities across America.

This is a very historic time to be working in health care whether its rural or urban.  Earlier this year, of course, President Obama signed the landmark health care bill, The Patient Protection and Affordable Care Act, which I’ll talk about shortly.  This act will expand the benefits of health insurance to 32 million people, many of whom live in rural areas, and of course it engages on a number of other fronts to improve the health and health care of the Nation.  Many rural health leaders helped lead the way in getting this historic bill passed and it’s a real tribute to their efforts.  

All of the attention on rural has also led to the President's Improving Rural Health Care Initiative, which I see is the theme for this meeting.  This initiative includes President Obama’s requests of the Congress for continued funding of HRSA's core rural health programs.  And, as Tom mentioned, it supports key activities such as recruitment and retention, HIT, collaboration, and the identification and application of best practices.  

I’m pleased to hear that many of you are focusing on these issues already, and I want to assure you that HRSA and ORHP are currently working to addressing these priorities.  The President’s recently released 2011 budget continues his support of the initiative.

As is the case for many of you, my rural background has greatly influenced the course of my career.  I was involved with the Office of Rural Health Policy from the very beginning, contributing to the creation of these programs when I worked in the Senate.  I remember how hard we fought to make these programs flexible enough to address the broad range of needs in rural communities. 

As I stand here now, over two decades from my first brush in rural health policy at the federal level in the legislative branch, I think we’re meeting those challenges.  Today we see the tremendous impact these programs are making in rural communities.  It is because of you, leaders across rural communities, that many of the major rural health issues are being addressed.  You understand the needs in your communities and the importance of collaboration, and your efforts are essential to sustaining and improving the health and wellness of rural Americans.   

I know this because I’ve had the pleasure of hearing about the innovative projects and important issues you’re focusing on.  For example:

In the Adirondack Park region of upstate New York a Network Development grantee, Hudson Headwaters, is attempting to stabilize, grow and sustain primary care services through provider education and recruitment services.

In Pearisburg, Virginia, an Outreach grantee, Carilion-Giles, is operating a free clinic and providing mental health services through their grant funds. 

In Iowa, a Network Development grantee, Agriwellness, created a sustainability plan for a seven-state network that focuses on behavioral health care services for agricultural communities.  The hotline services, free outpatient behavioral healthcare sessions, and farm family retreats provided by the network help to address the dire need for behavioral health care services in rural communities.

And related to behavioral health, you may be interested to know that we’ve put a new priority on behavioral and oral health, and we now have an Office of Strategic Priorities that is focusing on these important areas.  While we have a number of cross-HHS efforts initiated in both these areas, one of them, our new oral health web site, is up and running – you’ll find it at the top left side of the HRSA home page – and a site dedicated to behavioral health will follow soon.

I was also very pleased to hear that a number of grantees are addressing HIT – a key issue in the Affordable Care Act.  I understand that almost half of the Network grantees are currently focused on this.

And I was excited to hear that Southwest Healthcare services in my home state is addressing HIT needs in their community by developing a common patient registry system, creating a clinical data exchange service, and developing standardized claim forms and data sets.  

As Tom mentioned, the “Meaningful Use” Rule was just released.  It established a three-stage incentive payment program under CMS for the "meaningful use" of certified Electronic Health Record technology.  While adopting HIT will ultimately help to reduce medical errors and increase the quality of care, we know that right now there are a lot of questions with its implementation that need to be addressed.  HRSA is aware of your concerns and prepared to help support you, while also considering them in the program and policy work we do.

HRSA is co-leading, with the Office of the National Coordinator, a HHS rural HIT taskforce established by the Secretary to address HIT challenges.  Looking at the agenda for the next two days, I see that HIT will be addressed by a variety of speakers, and I’ll talk more about it later in my remarks.

These are just a few examples of the many dimensions of innovative and important work underway to serve rural communities across the nation.
 
Well, let me shift gears and focus on the Affordable Care Act to describe just a few of the ways it is designed to improve health care delivery, including rural health delivery. 

As we work to the ACA, we can see directly how it will profoundly affect the health and well-being of all Americans, and how it addresses issues that have been on the national agenda for nearly a century.

The Act already has instituted sweeping reforms: for example, it has made it illegal for insurance companies to deny coverage to children based on medical condition or disability (by 2014, adults will have the same protection phased in), and the ACA allows young adults to remain on their parents’ health insurance policies until they turn 26.

These new provisions build on other important initiatives. 

For example, we just learned last week that a record number of children now have health insurance, thanks to the expansion of the Children’s Health Insurance Program. President Obama signed that legislation as one of his first acts in office.  That action extended coverage to an additional 2.6 million children during FY 2009, and it was the primary reason we saw the percentage of children without health insurance drop from 10 percent in 2008 to about 8.2 percent last year.  That percentage of uninsured kids is the lowest level on record. 

The new law also focuses sharply on preventive illness and promoting health by investing in a public health prevention fund. Caring and focusing on people when they’re ill is clearly important, but so is doing whatever we can to prevent illness in the first place and mitigating the effects of chronic illness.  We can keep baling out water or we can patch this leaky boat that is health care.

To keep up with all the benefits of the new law as they come online, I encourage each of you to go to a new website called healthcare.gov and bookmark it.  For the first time ever, this site gives you the ability to see all your insurance options – public and private – in one place.  Viewers can see all the health plans available to them and compare benefits packages tailored to where you live.  Starting in October, the site will have price information too. It’s a remarkably easy-to-navigate website, complete with FAQs.  Please help spread the word about this valuable resource.

From HRSA’s portfolio of programs, we also are involved in implementing important changes.  In fact, when you think about how HRSA is affected by the Affordable Care Act, honestly, it would be easier to tell you how we’re not affected!  Together, last year’s Recovery Act and now the Affordable Care Act represent the most significant expansion of primary care in recent memory, and certainly the largest financial investment ever in HRSA’s programs.

As you may know, HRSA has front-line responsibility for many of the activities envisioned by the Obama Administration under the Affordable Care Act – as well as those already made under last year’s Recovery Act.

Specifically, HRSA oversees more than 50 different programmatic ACA authorizations, 35 of which extend well beyond 2011. The largest and most highly visible of these is $12.5 billion for the expansion of the Community Health Center system, and the National Health Service Corps – the NHSC – which I’ll be talking more about in a minute.

Generally speaking, the investments in HRSA under the Affordable Care Act are aimed at:

• Increasing Access to Primary Care Services;
• Investing in the Health Care Workforce;
• Supporting Maternal and Child Health;
• Broadening Access to 340B Drug Discounts; and
• Encouraging Prevention and Wellness.

Of all the challenges we face, of course, perhaps the most serious is reversing a long-deferred need to build a healthcare workforce adequate to meet the needs of the American people.  We need more clinicians with the appropriate skill and knowledge sets, in the places where they’re needed the most.  For example, to this end, about a month ago, Secretary Sebelius announced new investments in primacy care:

• $168 million to create primary care residency slots in community settings to train 500 new primary care physicians by 2015;
• $32 million to train 600 primary care physician assistants;
• $30 million to encourage 600 students to pursue careers as advanced practice registered nurses, nurse practitioners and nurse midwives;
• $15 million to 10 Nurse-Managed Health Clinics to provide additional training opportunities for nurse practitioners and other health care providers; and  
• $5 million to help state agencies develop innovative strategies to increase their primary care workforces over the next 10 years; I think we had over 40 state applications.

These announcements build on Recovery Act investments of half a billion dollars for the health care workforce and solid appropriations in 2009 and 2010 after many years of very anemic funding for health care workforce programs.  I want to be absolutely clear that the President and everyone at HRSA understand the importance of addressing this problem.

Speaking of the healthcare workforce, ORHP and the NHSC are working together to increase our investment in the National Rural Recruitment and Retention Network.  As many of you know, this matching service is like the E-Harmony of the health professions, linking providers who want to work in rural areas with communities who need them.
Last year, the Network helped to place more than 1,025 clinicians in remote counties and parishes across 49 states.

ORHP is also funding a new pilot program to provide technical assistance to the 22 Rural Training Track programs across the nation.  These Rural Training Tracks have the best record out there of placing physicians into rural areas – and our most recent research shows that more than 60 percent of residents in these programs choose to remain in rural practice.

In addition, ORHP is also funding a pilot program that supports getting more health professions students into rural training sites, and we’ll soon announce the funding of about 20 Rural Workforce Training Network programs.

Regarding the National Health Service Corps, all of you know the Corps to be an important player in the health workforce.  Well, going forward, because of the Recovery Act and Affordable Care Act, it will be a major player in terms of workforce distribution.  And its increase will notably improve access to care for rural populations.  That’s because about two-thirds of NHSC clinicians historically have taken rural assignments.

The Affordable Care Act expands the Corps’ reach by offering up to $145,000 over 5 years to repay primary care health professionals’ student loans in exchange for their service in high-need areas.  That amount comes close to the typical debt load carried by newly minted dentists and physicians.  The ACA increased the loan repayment amounts available to Corps participants and instituted very important additional provisions.

The President is very committed to this program and HRSA is fully engaged in implementing his pledge to increase the size of the Corps to some 8,000 practitioners over the next seven years.  And between that and our pushing the refresh button on the way HRSA deploys this program, you’ll see very soon that it’s not your father’s Oldsmobile!

And, in terms of access to primary care sites, the expansion of HRSA’s national network of 1,100 Health Centers, with more than 7,900 clinical sites, is, of course, a huge part of the Affordable Care Act’s impact on HRSA and ultimate impact on access to care for urban and rural communities.  More than half of all health centers serve rural residents – often through satellite or mobile clinics.

Today, health center grantees – thanks to the $2 billion boost they got from the Recovery Act – treat nearly 19 million patients.  The Recovery Act infusion allowed grantees to add 2 million patients to the ranks they serve.

Going forward and actually beginning now, HRSA is doing the work to draw down on the  $11 billion in funding provided by the ACA over the next five years for the operation, expansion and construction of health centers throughout the nation. 

This investment facilitates roughly doubling the number of patients health centers serve annually to about 40 million by year 2015.  The Act also authorizes $50 million a year to operate School-Based Health Centers through grants for facilities, equipment, or similar expenditures.

It is important to note that compromised access to health care providers and settings is not just a rural concern.  A similar number of urbanites face similar access problems.  
Access is important because across urban and rural underserved populations you see similar health problems: high rates of chronic illness and injury, unhealthy habits such as poor diets, too little exercise, tobacco use and too much alcohol consumption.

The Affordable Care Act places great emphasis on the need to incorporate wellness and prevention activities ever more strongly to both improve health status and also to bring down costs throughout the entire health care system.   One topic you’ll be hearing a lot about from this President and from the First Lady is a consistent message on healthy diets, healthy weight and physical activity.

As I mentioned earlier, it’s messaging backed by ACA investments in preventing chronic illness and promoting health.

Here, too, HRSA has a new role and a new opportunity to work with providers and communities across the country.  Two weeks ago, HRSA announced a funding opportunity for up to $5 million to support the creation of the Prevention Center for Healthy Weight.  Aligned with the First Lady’s Let’s Move Initiative and originating from the HHS Healthy Weight Task Force, this is a trans-HRSA, trans-HHS initiative funded by the Prevention and Public Health Fund that was created by the ACA. 

The Prevention Center for Healthy Weight will manage the Healthy Weight Collaborative, which will promote national efforts to develop and share promising interventions to prevent and treat overweight and obesity.  Some of the work of people in this room focuses on this area and I encourage all of you to join this effort.  I understand Nisha will provide more information on this during the ORHP update.

On another front, as most of you know, virtually everything HRSA does is done in partnership with state, local and community-based organizations.  We are often known as “The Access Agency”  or the “Safety Net Agency,” but we might just as well be called, “The Health Care Partnership Agency…”  And this has never been truer than it is under the authorities of the Affordable Care and Recovery Acts.

In terms of meeting our mission, there are very few instances where HRSA goes it alone. Let me give you just one quick illustration drawn from today’s agenda:

As we all know, Health IT is a cornerstone of future care management models.  And under the Affordable Care Act, the Administration has pledged $19 billion to make HIT happen on a large scale over the next few years.

Ironically, a lot of the early innovation in the use of electronic records and telehealth networks in this country was done in rural communities, but we know that vast swaths of rural practice remain beyond the reach of commercial broadband networks, including:

• As many as three out of 10 rural health clinics;
• More than a quarter of all critical access hospitals; and
• 2,500 small rural practitioners, who are the backbone of family care in many communities.

This is not a problem that will be solved quickly.  As I said earlier, we’ve established an HHS Rural Health IT Task Force, and we are currently looking at ways to provide rural practitioners with resources and funding opportunities.

You may know that HHS chose 15 Beacon Communities nationwide in May to receive $220 million for HIT pilot projects to demonstrate the feasibility of widespread networks in places as diverse as Oklahoma, Mississippi, Maine, North Carolina and Utah.

This initiative drives a dual outcome: to create jobs and to expand community college IT programs needed to produce the necessary technical workforce.

It also contains what we need on so many levels: an integration of services and workforce – software; hardware; humanware.

It’s the theme that resonates throughout the multitude of changes promoted by the Affordable Care Act: integration –  integration of services within clinical sites; integration and coordination among providers; integration across regions.

Similarly, we are pushing hard within HRSA to drive integration across our programs, and to connect to others in HHS and across the federal government.  And of course, I urge you to continue to do the same with your rural partners and look for ways to further leverage and align your activities.

To illustrate in concrete ways how we’re approaching alignment, our Offices of Pharmacy Affairs and Rural Health Policy are working together to benefit many rural facilities.

On July 19, our new Office of Pharmacy Affairs Director, Krista Pedley, and Tom (Morris) hosted a Webinar to announce newly covered entities for the 340B program under the ACA.  These include rural referral centers, critical access and sole community hospitals, and certain children’s and freestanding cancer hospitals. Enrollment starts August 2; you can visit www.hrsa.gov/OPA for application information.

I know the ORHP is excited to work with the Office of Pharmacy Affairs to identify the new rural entities for the program.  It will provide a great benefit to them and their patients by providing access to affordable pharmaceuticals. 

In closing, I want to leave you with a request.  Partnership is a two-way street.  That means we need to hear from you.

The Affordable Care Act presents great opportunities for expanded coverage and services to millions more people.  To fully engage these opportunities for rural populations, we need to hear from you.

We are videotaping key sessions for your review and to share with your colleagues when you return home, and we’ve positioned computers at registration so that you can give us the suggestions and comments we seek.

We’ve also created an e-mail address – ruralhealth@hrsa.gov – specifically to give you an opportunity to ask questions or provide comments, suggestions or express any areas of concern that you would like us to address.

Our ORHP staff will monitor the questions over the next few days.  They’ll address what they can at the close of this meeting and compile everything else so that we follow up on your concerns and ideas.

So please share your thoughts, since they will inform us and benefit many others, and thank you again for all that you do on behalf of rural communities.