Remarks to the 118th Annual Convention of the American Psychological Association

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by HRSA Administrator Mary K. Wakefield

August 14, 2010
San Diego, CA

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Good morning everyone, and thank you for coming out so early today. And thank you Dr. DeLeon for that kind introduction. Pat is truly one of our heroes. As a new member of the Institute of Medicine, I know he will be a tireless and outstanding representative for all psychologists, and even more importantly, for the health of all the people who are most vulnerable across the nation.

I am very pleased to be here to talk about the Health Resources and Services Administration – also called HRSA – which I administer, and our role in ensuring that vulnerable and underserved Americans can obtain high-quality and affordable health care.

I’ll also discuss the crucial role that mental health professionals play as an integral part of virtually all our programs and activities, and how we can support the training of mental health professionals and the integration of mental and behavioral health services with primary care.

For those of you not familiar with HRSA, I’d like to say a few words about who we are and what we do. We are an agency of the Department of Health and Human Services, with a budget of $7.5 billion. We are the primary federal agency responsible for improving access to health care services for people who are uninsured, isolated, in rural areas, or medically and economically vulnerable.

Within HRSA’s portfolio, we support a network of 1,100 health center grantees across the nation  that provides primary health care to nearly 19 million patients at  more than 7,900 sites, ranging from large medical facilities to neighborhood clinics and mobile vans. Charges for services are set according to income, and only nominal fees are collected from the poorest patients. Today, over half of all mental health services in the United States are provided in primary care settings.

This network, by the way, is going to be greatly expanded thanks to the Affordable Care Act, which I’ll talk about shortly.

HRSA also helps to ensure the adequacy of the health care workforce by supporting curriculum development and through scholarship and loan repayment programs offered by our Bureau of Health Professions, which provides incentives to clinicians to practice in the nation’s most underserved areas.

Through the National Health Service Corps, a signature program, we place professionals where they're needed most. The Corps provides scholarships and student loan repayments worth up to $50,000 in exchange for two or more years of service in a shortage area.

The Corps currently has a field strength of more than 1,000 mental and substance abuse services professionals, including psychologists, psychiatrists, licensed professional counselors, marriage and family therapists, psychiatric nurse specialists and social workers.

By the way, the Corps is currently recruiting 4,000 new members to receive loan repayment awards. There are over 1,900 vacancies for behavioral health jobs, including 408 for clinical psychologists.

Many Americans know us for our administration of the Ryan White HIV/AIDS Program, whose grantees provide top-quality care to more than a half-million low-income and uninsured people living with HIV/AIDS, or half of all people living with this disease.

Then there is the Maternal and Child Health Bureau, which leads the federal government's efforts to improve the health of mothers and their children. Every year, its block grants to states afford health services that reach 6 out of 10 women who give birth in the U.S. This program, too, is expanding under health care reform.

HRSA also administers the 340B Drug Pricing Program, which gives safety-net providers access to discounted pharmaceuticals, a program that also was expanded significantly in ACA.

In addition to those core programs, we also fund a range of others that include oversight of the nation’s Poison Control Centers; federal Organ Procurement and Donation efforts; the National Vaccine Injury Compensation Program; and the Office of Rural Health Policy. I will be happy to respond to questions about any of these programs.

That's a brief summary of our portfolio. And access to mental health care and to mental health care professionals is a key component of our programs. For example:

In the community health clinic network, over 3,600 mental and substance abuse counselors provided services to more than 758,000 patients last year (for a total of 3.8 million patient visits in 2009). There were 318 psychologists working at health centers in 2009 – and I’ll be the first to say there is definitely room for growth there.

Two thirds of all the health centers provide mental health treatment or counseling services, and one third provides substance abuse treatment and counseling. Last year, health centers provided substance abuse services to 115,000 patients.

On the maternal and child health front, HRSA supports more than 100 Healthy Start Program sites across the country that provide depression screening, outreach, case management, and educational activities for women in areas with high rates of infant mortality and shortages of health care providers.

I visited a Healthy Start site in Philadelphia a few months ago and saw first-hand the efforts being made there to help virtually all young mothers, from very vulnerable environments, learn to manage the stresses they faced in their health and the health of their young children.

Over the past four years, through our Maternal and Child Health Bureau, we have distributed over a million copies of our publication on post-partum depression.

You also may have heard of our “Stop Bullying Now” campaign that provides essential resources to school staff; health, safety, mental health, and law enforcement professionals; youth organizations; and community leaders to address bullying behaviors in youth and to launch prevention activities.

We just partnered earlier this week with the Department of Education, the Department of Justice, three other federal agencies, and about 150 national organizations – including corporate executives from the likes of C-SPAN, Facebook, and the Cartoon Network – who are concerned about this challenge facing our youth and committed to considering contemporary strategies for doing something about it. You can learn more by visiting HRSA’s Web site and looking up the Stop Bullying Now campaign.

As for the Ryan White Program, $81.5 million of HIV/AIDS funds were devoted to mental and behavioral health services in 2008, including outpatient substance abuse services to over 31,000 clients.

And in our workforce programs, of course many of you are familiar with the Graduate Psychology Education Grant Program, which supported more than 400 graduates and trainees in 2009-10.

It is against this and a much broader backdrop of activities that the administration added to HRSA’s portfolio by providing $2.5 billion to HRSA under the Recovery Act last year to increase the size of the National Health Service Corps; to expand, improve and renovate the health center system; and to provide greater education and training opportunities.

Of the $2.5 billion from the Recovery Act, we received $200 million to counter projected workforce shortages in health care by expanding training and educational opportunities. These new funds are expected to train 8,000 students and credentialed health professionals by the end of this fiscal year. To date, thanks to Recovery Act investments, health centers have reported serving an additional 85,000 patients -- accounting for more than 330,000 mental health visits – again as a result of Recovery Act expansion. The additional funding also supported more than 170 mental health professionals retained or hired to work at health centers. This was particularly important when people lost their jobs and health insurance, and the number of people who presented mental health problems markedly increased.

And the President’s budget for 2011 includes $25 million to expand mental health services at 125 health centers.

In addition to an influx of resources through the Recovery Act, when the Affordable Care Act was passed earlier this year, HRSA was named the lead for more than 50 provisions in the new law. The main goals of the Act – as they relate specifically to HRSA’s mission – are targeted to four areas:

• increase access to primary care;
• invest in the health care workforce;
• support maternal and child health, and
• expand access to discount drugs.

To accommodate this work, in recent months we have been realigning resources and priorities to implement the many provisions of the Affordable Care Act that fall under our jurisdiction – the largest number of provisions after those involving CMS.

Under the Act, HRSA is committed to expanding the integration of behavioral and mental health into primary care. And we are currently developing guidance for this commitment – including the Health Center New Access Point guidance announced just about a week ago for the creation of new health centers and new satellite sites for $250 million – that requires the delivery of primary medical, oral and behavioral health services.

At the same time, we are moving as rapidly as possible to meet the surge in demand that health care reform will generate between now and 2015.

How this surge in demand for health services will affect psychologists and access to mental health care is hard to say right now. Increased access to health care services is facilitated by a number of provisions in the Act. For example, we know that the Act will reduce premiums for comparable coverage in the individual market by anywhere from 14 percent to 20 percent by bringing new people into the market and streamlining administrative costs.

Insurance coverage for mental health services and related reimbursements for mental health services by insurers has always been a “challenge.” The Obama Administration addressed a long-standing disparity in our country’s health care system in January, when it issued new rules on parity in the treatment of mental and substance abuse disorders. As you know, the new rules prohibit group health insurance plans from restricting access to care by limiting benefits and requiring higher patient costs than those that apply to general medical or surgical benefits.

For those of us who work in the provision or administration of health care services, this change was long overdue.

Let me pause here for a moment to say that all of you – whether caregivers, parents, sons or daughters, spouses, employers, disabled, or seniors – can easily get all kinds of information on what the new law means for you and better understand coverage and other related reform details: how to find insurance options, compare care quality, understand details of the new law, or find information tailored to your specific circumstances. Just go to www.healthcare.gov. If you take away nothing else from my remarks this morning, please take this point with you.

The biggest effect the Affordable Care Act has on HRSA’s work involves the provision of primary care services and investments in the workforce. The Act provides $11 billion in funding for the operation, expansion and construction of health centers throughout the nation. This investment will help health centers provide quality preventive and primary health care—and, of course, mental health care—to nearly double the current number of patients, regardless of their insurance status or ability to pay.

The health reform legislation provides new training and education opportunities for mental health professionals in several ways:

• It establishes a loan repayment program for pediatric specialists and providers of mental and behavioral health services to children and adolescents who are or will be working in underserved or shortage areas for at least 2 years.

• It authorizes a grant program for School-Based Health Centers to provide comprehensive preventive and primary health care services to medically underserved children and adolescents.

• It creates a new school grant program for training in social work, graduate psychology and child and adolescent mental health.

The law also affects mental health services indirectly through a number of provisions. From our perspective, we’re working hard to cast mental health services as an essential component of primary care.

Even before the Affordable Care Act was passed, HRSA had already taken important steps toward integrated health care services. Immediately after I was appointed administrator of HRSA in early 2009, I realigned the agency’s organization and strategy to position us in the forefront of integrated approaches to health care.

In terms of the organization, our 10 regional offices across the country were realigned to focus more on strengthening links between states and communities and coordinating technical assistance, and to become more active in the recruitment and retention of the primary care workforce in their jurisdictions.

While HRSA has historically had a Chief Medical Officer, I changed that and created a new position for a Chief Public Health Officer to crystallize and oversee our public health agenda, including reviewing all our programs and policies from a public health perspective to promote disease prevention and healthier living and to drive a thematic link between primary care and public health across our programs.

Six months ago, we created the Office of Strategic Priorities, which examines and responds to priority health issues. Its two key aims are to help advance the integration of behavioral health services and primary care and to promote access to oral health care.

With regard to behavioral health, the Office:

• has established goals and priorities to improve behavioral health outcomes and eliminate disparities; and
• has conducted a behavioral health inventory and related analysis across HRSA’s programs.

We have just hired a psychologist to lead this behavioral health component of OSP, I think she’ll be known to many of you.

In terms of our strategy, we implemented a new approach emphasizing and incorporating public health into all our activities, and we have instituted the expectation that mental and substance abuse health care be integrated into all HRSA programs. Some examples:

• Our Bureau of Primary Health Care awarded $4.3 million last year specifically to integrate behavioral health care into primary care services at health centers.

• We have new pilot programs for medical homes where patients receive care from a team of primary care providers including doctors, nurses, social workers, and behavioral health counselors who check up on patients and make sure they’re managing their chronic conditions.

• We have revised our program reporting guidance to include Screening, Brief Intervention and Referral to Treatment (SBIRT) as a service under Federally Qualified Health Center grants.

• We fund education programs to prevent stigma and discrimination against people with HIV/AIDS.

• We have a Special Project of National Significance for integrated mental health services to American Indians and Alaska Natives who are HIV-positive.

These strategic and operational changes have required all of us to shift our focus from the treatment of acute conditions to incorporating a far more substantial focus, across all our programs, on illness prevention and health promotion — not just patient by patient, but also community by community, going upstream of acute care to embed this focus.

However, no single entity can meet the challenge of integrating mental health and primary care –or expanding the health care workforce – alone. The task requires wider collaboration, integration, networking, and coordination among public and private partners.

Federal partners include SAMHSA, the Substance Abuse and Mental Health Services Administration, the CDC and the National Institute on Alcohol Abuse and Alcoholism, as well as agencies with a role in providing care (such as the Indian Health Services), that are performing research (NIH), or that have oversight responsibilities (FDA). Private partners include individuals like you and organizations like the APA.

Let me just share a couple of examples of how we are collaborating with our federal partners to integrate mental health into primary care, especially for vulnerable and underserved communities. As an aside, the HHS secretary has made cross-agency work a very high priority.

• HRSA will contribute $350,000 a year for the next four years to a joint national training and technical assistance center with SAMHSA for the integration of primary and behavioral health care.

• We are working with the White House Office of National Drug Control Policy (or ONDCP) to develop performance measures for the National Drug Control Strategy as it relates to the integration of substance abuse care with primary care.

Health centers are a focus of the ONDCP National Drug Control Strategy because they promote the integration of behavioral health into primary care with a focus on screening measures for substance abuse.

• HRSA and SAMHSA have joined forces to identify effective ways for health centers nationwide to provide these types of services, including a pilot with 8 health centers in Maryland.

• HRSA and SAMHSA are about to begin a pilot with the National Guard to help returning soldiers in New Mexico and Kansas locate primary care and behavioral health services that are available to them locally.

We are also exploring staff exchanges with the CDC and forging a three-way collaboration with the Centers for Medicare and Medicaid Services to implement the Mental Health Parity and Addiction Equity Act, and the CHIP (Children’s Health Insurance Program) Mental Health Parity Act. 

Looking forward, our collaboration with the APA and all mental health professionals is going to be increasingly important, especially as demand for services grows in coming years. Further, this partnership is a fundamental component of the integration of mental health and primary care. It is no longer a question of having one without attention to the other.

I also recognize that hiring psychologists to work in shortage areas has always been a challenge, but that doesn’t mean we set the challenge aside as insurmountable. Using what I was taught by Pat DeLeon – that lack of success in moving an agenda shouldn’t mean we abandon the agenda, it should mean we find the right time to come back to the agenda and the right dimensions to move it forward – I  think that time is now. We need your expertise woven into our programs now more than ever. I am personally committed to making sure that mental health is fully integrated into the provision of primary health care, and that we successfully join forces to address the challenge of meeting the mental health needs of America’s vulnerable and underserved populations.

With the passage of health care reforms, a renewed focus on prevention and public health, expanded partnerships with all stakeholders, and yes – a much-needed infusion of funding – we now have unprecedented opportunities to collaborate, share resources, coordinate activities, increase efficiencies, and ultimately improve the health outcomes of the American people, program by program across HRSA’s portfolio.

And, as a first indication of our commitment, HHS Secretary Kathleen Sebelius will be announcing any moment, figuratively speaking, $2.6 million in Graduate Psychology Education Program grants to expand mental and behavioral health training programs. This is news that just cleared yesterday afternoon and that I have with me today.

These 3-year awards to 19 accredited schools and other public and private entities represent a 60 percent increase in fiscal year 2010 graduate psychology education program funding over last year. This is, we believe, an important program that supports an integrated approach to health care services and services populations in need. If you are interested in knowing who the recipients of these funds are, I have a list with me.

Let me close by saying that I look forward to continuing to work with the APA to advance our shared agenda.

Thank you.