Remarks to the Ryan White All-Grantees Conference

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by HRSA Administrator Mary K. Wakefield

August 23, 2010
Washington, D.C.

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Thank you, Deborah (Parham Hopson), for that wonderful introduction – and thanks to all of you for coming to Washington during what is generally considered to be the worst possible time of year.

Most people are trying to get out of the District during the dog days of August, so I consider it a mark of your dedication that you’re all here.

We gather this morning – almost 2,500 strong – to commemorate and celebrate two decades of progress in a program that literally saves lives. We come to honor the memory of the friends, neighbors and colleagues who were taken from us by this virus, especially the boy from Indiana who lent his name to our collective cause.

Ryan White.

I am both humbled and privileged – as are we all – to be standing in the same place this morning with his mother, Jeanne, whose personal story transcends heroism. She is a reminder to us all of what is possible when the human spirit rises in the name of love to fight a righteous fight.

I wish I could stand up here and say this battle is over. But we all know it’s not. That fight is why we’re here today.

We all know that the stigma Jeanne and Ryan struggled against more than 20 years ago still hovers over this disease today in too many places across the Nation – even as 56,000 people are newly infected each year; and even though nearly half of all Americans now know someone personally who is living with the virus.

We know there are still practices that won’t see HIV/AIDS patients; still places where people have to travel many miles to reach one of the 900 Ryan White providers that will treat them with dignity and respect; still towns and neighborhoods where some biases force people to extreme measures in seeking treatment.

And we are acutely aware – and deeply concerned – about health care professions shortages that are being felt more in the HIV/AIDS community than in many others.

I come from a small town in North Dakota, out in the middle of the Great Plains, halfway between New York and San Francisco, just a little further north than both – a heavily rural state where there have never been enough doctors, dentists, nurses, psychologists and others … you name it … to go around.

So I take these access-to-health care issues very personally. And from the earliest days of my career, working in the kitchen of a small rural hospital as a student nurse in high school, I pretty much made up my mind to be one more voice trying to something about it.

I can’t say I ever expected as a young nursing student to be named the Administrator of a federal health care agency with 80 different programs and more than 3,000 grantees. But from the moment President Obama appointed me to this job, I thought: “Okay, here’s another opportunity as a health care provider to try and make a dent in some of these problems.”

For each and every person here today, I hope you feel the same way about it. Because the opportunity to make real and measurable progress in our 30-year fight against this virus – and to improve the lives of those it touches – I believe has never been better…

Beginning with the President’s recently announced National HIV/AIDS Strategy – the first document of its kind, which will guide and coordinate the federal government’s $19 billion annual response to the disease and its social consequences – we are poised, with your help, to make dramatic improvement.

And even larger gains are possible over the next 5 years – in access to testing; in improving health insurance coverage; in addressing disparities in care – as Health Care Reform begins to take hold.

I’ll return to this in a moment, but first I want to bullet just a few things that this President and this Administration have already done, just to underscore some of what Secretary Sebelius mentioned a moment ago.

The President has:

• Supported and advocated for the reauthorization of the Ryan White program, ensuring continuity of our efforts until 2013;
• Approved $163 million in Ryan White budget increases since taking office – as well as authorizing $25 million in ADAP “gap” grants to states just a few weeks ago;
• Lifted the Travel Ban, clearing the way for the International AIDS Conference to be held in the U.S. for the first time in more than a decade – here in Washington in 2012.
• Launched a series of 14 local and regional HIV/AIDS strategy conferences, attended by more than 4,000 people, in such widely divergent locales as Atlanta, Albuquerque, Mississippi and Puerto Rico to make sure that this administration is as well informed as possible about the issues most immediately important to all of you … our partners in these efforts.

All of this was designed to get us where we are right now: with HIV/AIDS integrated into the larger strategy that underlies Health Care Reform.

As the President has put it: “When one of our fellow citizens becomes infected with HIV every nine-and-a-half minutes, the epidemic affects all Americans.”

That said, we well recognize that there are certain persistent issues involved in the care and treatment of those living with this disease – issues that the Ryan White program was specifically tailored to address.

To quote the President: “Gaps in essential care and services for people living with HIV will continue to need to be addressed – along with the unique biological, psychological, and social effects of living with HIV. Therefore, the Ryan White HIV/AIDS Program and other Federal and State HIV-focused programs will continue to be necessary.”

And as we’ve so recently seen, the Administration has backed up these words with meaningful and necessary action.

Pivotal in addressing the National HIV/AIDS Strategy, the Affordable Care Act mandates that high-risk insurance pools be established in every state to provide coverage to uninsured people with chronic conditions – including, of course, HIV.

In 2014, Medicaid will be expanded to all lower-income individuals (those earning $15,000 or less) under age 65.

Those with incomes of around $43,000 who are uninsured will have access to Federal tax credits and the opportunity to purchase private insurance coverage through competitive insurance exchanges.

And new consumer safeguards will better protect people with private insurance coverage by ending discrimination based on health status and pre-existing conditions.

We all know that these are just part of the answer to the long-standing problem of health disparities among those living with HIV/AIDS – 21 percent of whom don’t know they’re infected, in part because of the dearth of screening services and primary care in too many communities.

You’ll be hearing more during this meeting about how the CDC and HRSA plan to attack this problem. But suffice it to say for now that more needs to be done in our underserved communities to reduce the exposure rate. And since we know that most HIV-positive people who are aware of their condition undertake conscientious efforts to reduce their risks of transmission to others, one means of cutting that 21 percent rate is to expand screening. 

Once we’ve improved detection, the National Strategy calls for a three-point approach to assisting those with HIV/AIDS, by…

• First, establishing a seamless system to immediately link people to continuous and coordinated quality care when they are diagnosed with HIV;
• Secondly, taking deliberate steps to increase the number and diversity of available providers of clinical care and related services for people living with HIV; and
• Third, by supporting people living with HIV who have co-occurring health conditions and challenges meeting their basic needs.

This is where HRSA comes in, across the nation.

Everything that I just laid out may seem like a tall order to fill – a complicated jig-saw puzzle with a lot of pieces.

But here is where the Affordable Care Act really comes into play.

HRSA will oversee more than 50 different authorizations under the Act – 35 of which extend well beyond 2011. And the federal government’s expertise in providing care to people living with the virus resides in HRSA and all of you, through the Ryan White program.

In terms of technical know-how, frontline experience, and policy acumen, HRSA’s HIV/AIDS Bureau under Associate Administrator Deborah Parham Hopson is the recognized leader in this arena. I could run down a long list of names in that bureau before I came to one who isn’t immediately familiar to all of you as a national expert.

So HRSA has a key role to play.

The largest and most visible of the ACA authorizations, of course, is $11 billion to double the size of the Community Health Center system, which already serves one of the largest primary care patient populations in the nation, public or private.

This expansion will be unprecedented in the 35-year history of the program, and it will vastly increase the reach and availability of services in the 6,200 communities nationwide that we know are experiencing shortages of screening facilities and other needed primary care supports – such as oral and behavioral health – that are crucial to individuals living with HIV.

The patient population is expected to grow from 19 million people today to about 40 million in the next 5 years. And we are going to need to substantially grow the current number of CHC clinics from the current 7,800 sites.

These investments will build upon the expansion already begun under the Recovery Act, which included:

• $2 billion for health center operations, staff hiring, equipment upgrades, and construction and renovations -- which extended care to more than 1.6 million new patients in dire need during the economic recession, many being seen in health centers for the first time as they lost their jobs and their health insurance; added 127 new health center sites; and allowed the hiring of 10,000 new CHC staff in 2009; and…
• And the Affordable Care Act infused $9 billion for new Health Information Technology systems to improve the continuity, efficiency, cost-effectiveness and quality of care throughout the system.

So far, I’ve described the administration’s health care reform plan, the physical infrastructure that supports it, and how it supplements the National HIV/AIDS Strategy.

We can be confident that the health center expansion will greatly increase HIV screening services, and help us reach the estimated 220,000 people nationwide who are unaware that they’ve been exposed to the virus. Already, we know that screenings rose 13% last year as the Recovery expansion got underway – to almost 754,000 screenings.

The next obvious concern is the workforce – because the plan can only work as well as the people implementing it.

Here, too, the Administration is hard at work.

Last year’s Recovery Act provided $500 million for HRSA workforce development programs, including:

• $200 million for the largest HRSA-managed training programs – those are Title VII and VIII of the Public Health Service Act – for training and loan repayment grants in support of 12,000 primary care clinicians (8,000 of whom are expected to graduate right about this time).
• $300 million to double the size of the National Health Service Corps to more than 6,000 primary care clinicians. These dentists, doctors, nurses and behavioral health practitioners qualify for up to $50,000 in academic debt relief in exchange for serving in our hardest hit shortage areas.

So, this help through the Recovery Act is already on the way.

Under the Affordable Care Act, more will be coming.

While access to health care is certainly about better access to insurance coverage, the ACA provides critical planks in the training platform that will allow us to grow the workforce to scale as reform takes hold. In recent weeks, we have announced:

• $168 million to expand the number of primary care residency slots to produce 500 additional providers by 2015;

• $32 million to train 600 primary care 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 proven training and clinical care innovation that will speed our ramp up.

• $5 million to assist state agencies in planning strategies tailored to their unique circumstances to increase their primary care workforces by 10 to 25 percent;

• Reauthorization for all seven of HRSA’s nursing workforce programs – which represent the primary source of Federal funding for nursing education – to both rapidly increase faculty and diversity within that profession;

• Additional tax relief for those health care professionals was provided for those who practice in underserved areas as a condition of receiving student loans under state programs;

• Additional grant funding of $230 million over 5 years to establish teaching health centers; increase primary care residencies in community-based sites; and fund additional residents;

• Also important to people living with HIV/AIDS, $2.6 million in Graduate Psychology Education grants to expand mental and behavioral health training programs at 19 accredited institutions – for a net budget increase of 60 percent over FY2010.

If these numbers sound somewhat bewildering at times, that might be a sign of the enormity of this effort. Added together, the Recovery Act and the Affordable Care Act represent the largest expansion of primary care in this country in decades – if not in history.

And that can’t help but make life better for people living with HIV/AIDS.

These service expansions will piggyback on several successful Ryan White initiatives that have proven the importance of integrating oral and behavioral health into primary care – as we continue to evolve our health center clinics into true “Health Homes.”

All of this is directly helpful in that about a third of our 900 Ryan White clinics are Health Centers.

The ability to “treat the whole patient” – and his or her coexisting conditions – in one place, at one time, is now as integral to health reform as it ever has been in Ryan White. With the expansion of the Health Home model in the years ahead, we would expect many more health centers to be in a position to offer these integrated services.

Here’s an illustration:

In the Ryan White program, behavioral health – including outpatient substance abuse services – is now an $81 million effort that reaches 31,000 clients;

Today, two-thirds of health centers provide mental health treatment or counseling services that reach more than 750,000 people per year; and one third now provide substance abuse treatment and counseling that served 115,000 people just last year alone.

Those centers now employ over 3,600 mental and substance abuse counselors. And the President’s budget for 2011 includes $25 million more to expand mental health services at 125 health centers.

The Ryan White program also includes a significant oral health component: more than $60 million has been committed under various HIV/AIDS initiatives that have reached more than 120,000 Ryan White clients since 2006.

At the same time, the Health Centers have ramped up their oral health component – a 131% increase since 2001. Today, nearly nine out of 10 health centers provide preventive oral health care services, either on-site or by paid referral, reaching more than 3 million patients annually.

In FY 2009, HRSA awarded $8.7 million to support oral health service expansion at health centers, which now employ around 2,300 dentists and 900 hygienists nationwide.

This system is not yet as seamless as we would like it to be; and behavioral and oral health are services that are yet to be consistently offered, everywhere. But as the provisions of the Affordable Care Act take hold in coming years, I think we will see progress on both fronts.

As that system grows, we will continue to look to the Ryan White program as a really shining example of a community-based primary care model that works – one of the most successful in the history of U.S. public health -- thanks to all of you.

In the face of a virus that had taken the lives of 575,000 Americans, you rose to that fight in the name of a boy from Indiana. And as a result the dying stopped.

Our challenge today lies in how best to serve the living; and our opportunity to do that job well has never been better than it is right now.

For all that you do in partnership with us, HRSA offers our heartfelt thanks!